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Med Surg/Chapters 25 and 86-Respiratory System and Disorders questions with correct answers respectively.
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Med Surg/Chapters 25 and 86-Respiratory System and Disorders questions with correct answers respectively.

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  • August 16, 2024
  • 33
  • 2024/2025
  • Exam (elaborations)
  • Questions & answers

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  • med surgchapters 25 and 86 respiratory system and

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  • Medical surgical nursing
  • Medical surgical nursing

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Med Surg/Chapters 25 and 86-
Respiratory System and Disorders
questions with correct answers
respectively.

A client has a defective cranial nerve I. What data would the nurse gather in order to determine
function?



a. Use a tuning fork to determine bone conduction.

b. Ask the client to smell and identify a variety of scents.

c. Ask the client to open and close the eyes.

d. Ask the client to stick the tongue out and say "ah." ANS - Answer: b

Cognitive Level: Apply

Explanation: Nerve endings in the septum and nasal passages are responsible for the sense of smell. The
olfactory nerve (cranial nerve I) carries these nerve impulses to the brain. A client who is unable to
identify scents will likely have a defective cranial nerve I.



A client is eating supper and begins coughing. What is the appropriate first action by the nurse?



a. Insert fingers into the mouth to do a blind sweep and remove object.

b. Lay the client flat and perform chest thrusts.

c. Pat the client on the back to assist with dislodging the foreign body.

d. Do nothing. Coughing will usually dislodge the foreign body. ANS - Answer: d

Cognitive Level: Apply

Explanation: If a portion of food accidentally becomes lodged in the larynx, coughing can usually
dislodge it. If not, the air passage may be blocked; such a blockage can be fatal unless proper emergency
treatment is given. Nurses are given special training in treating obstructed airways and cardiopulmonary
resuscitation.

,The rescue squad brings a client into the Emergency Department who has a blocked airway after choking
on a piece of steak. The client is unresponsive and resuscitation efforts are continued with a bag-valve-
mask. What action by the nurse is a priority?



a. Gather equipment for an emergency tracheotomy.

b. Intubate the client.

c. Start an intravenous infusion.

d. Perform a blind finger sweep. ANS - Answer: a

Cognitive Level: Analyze

Explanation: In the event of a blocked airway, a tracheotomy may be needed. This is an artificial
opening, either temporary or permanent, into the trachea. Without additional training, it is outside the
scope of practice for the nurse to intubate the client. In addition, it would not be an appropriate action
considering that the airway is obstructed. Performing a blind sweep may cause further dislodgement of
the foreign body. Starting an IV is not a priority action and will not improve the outcome if the airway is
obstructed.



The nurse is caring for a client with left lower lobe pneumonia. What nursing action would assist in
improving oxygen delivery to the lungs and tissues?



a. Encourage frequent coughing and deep breathing.

b. Position the client with the head of the bed slightly elevated.

c. Provide deep endotracheal suctioning.

d. Use a bag-valve-mask to ventilate the client. ANS - Answer: a

Cognitive Level: Apply

Explanation: Many factors can cause a decrease in gas exchange, including immobility,
thoracic/pulmonary surgery, or pneumonia. Encouraging frequent coughing and deep breathing should
assist in improving oxygen delivery to the lungs and tissues. Supplemental oxygen may also be ordered
to improve arterial oxygen levels (O2 saturation).



What intervention provided by the nurse would assist the client with early chronic obstructive lung
disease to improve efficiency of lung function?



a. Administer breathing treatment with a bronchodilator.

,b. Provide smoking cessation information.

c. Perform chest physiotherapy.

d. Encourage coughing and deep breathing. ANS - Answer: b

Cognitive Level: Apply

Explanation: Smoking can decrease the efficiency of the respiratory system. Nicotine causes a decrease
in bronchial diameter, constriction of blood vessels, paralysis of cilia (which assists in moving foreign
particles out of the respiratory tract), and it can destroy lung tissue itself over time. These factors can all
result in a decrease in gas exchange.



The nurse is preparing a client for a bronchoscopy. What nursing actions are essential prior to the
procedure? Select all that apply.



a. Administer an enema.

b. Detail the complications that can occur.

c. Give mouth care.

d. Observe for any loose teeth.

e. Explain the procedure. ANS - Answer: c, d, e

Cognitive Level: Apply

Explanation: Food and fluids are withheld for 6 to 8 hours before a bronchoscopy. Give mouth care
immediately before the procedure to prevent bacteria from being introduced into the lungs. Explain the
procedure to the client, who will most likely remain awake. Be sure that any dentures are removed.
Note any loose natural teeth because the bronchoscope may loosen or dislodge a tooth, which could
lead to aspiration. An enema administered pre-procedure is not required and has no benefit for the
client. The care provider performing the procedure is responsible for detailing the complications prior to
the client signing the informed consent.



A client has a positive tuberculin skin test. What action by the nurse is appropriate?



a. Administer another tuberculin skin test.

b. Administer a tine test.

c. Send the client for a chest x-ray.

d. Prepare the client for a bronchoscopy. ANS - Answer: c

, Cognitive Level: Apply

Explanation: A person who is a positive reactor usually remains so for life. Thus, once positive, the TST
test is usually not repeated. If a person has a positive reaction to the testing, a CXR and a sputum culture
should be done to determine if the lungs are affected. In addition, some individuals may develop a
severe allergic reaction to the test. Another tuberculin skin test is unnecessary. The tine test is another
form of a tuberculin test that is not required after a positive tuberculin. The bronchoscopy is not
required at this time and may be considered after the chest x-ray results are returned if there are lesions
present.



The nurse is ambulating a client with chest tubes to the bathroom when the tube becomes disconnected
and falls on the floor. What is the priority action by the nurse?



a. Reconnect the tubing.

b. Double clamp tube close to the chest wall.

c. Allow the client to ambulate to the bathroom.

d. Place the client in the supine position. ANS - Answer: b

Cognitive Level: Apply

Explanation: If the tubes become disconnected, double-clamp all tubes close to the chest wall and
summon assistance immediately. This is an emergency situation requiring prompt intervention. If air
enters the chest cavity, the person's lungs will collapse. Therefore, the client should not continue to
ambulate to the bathroom. The client should be placed in Fowlers position, not supine. Reconnecting
the tubing that has fallen on the floor may introduce pathogens into the lungs when reconnected and
should not be done.



The nurse is preparing a client for abdominal surgery. What action by the nurse can prevent
postoperative atelectasis?



a. Suction the client every 2 hours.

b. Administer supplemental oxygen.

c. Administer an inhaled bronchodilator.

d. Instruct the client about the use of incentive spirometry. ANS - Answer: d

Cognitive Level: Apply

Explanation: The healthcare provider will probably order breathing exercises to help the client build up
respiratory capacity. These are usually done with the aid of the incentive spirometer. Instructions will

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