Respiratory practice questions

Question 1

A 64-year-old client with influenza A pneumonia has been receiving bilevel positive airway pressure (BiPAP) by full face mask in the intensive care unit for 6 hours. The client is alert, keeps pointing at the mask, and becomes more restless each time the nurse cannot understand what the client is trying to say. Which action should the nurse take?

Accepted Answer

A: Give the client a writing board and ask questions that can be answered yes or no. A client on BiPAP by full face mask cannot speak clearly, and being unable to make needs known is one of the most frightening parts of noninvasive ventilation. Frustration turns into anxiety and restlessness, and an anxious client breathes faster, fights the machine, and is more likely to pull the mask off.

The nurse gives the client another way to communicate while the therapy continues: a writing board, a letter or picture board, and questions that can be answered with a nod or a hand signal. The nurse allows time for each answer and checks the common needs first, such as pain, thirst, mask discomfort, the need to void, and fear. Being understood lowers anxiety, which helps the client tolerate the mask.

Question 2

A client with suspected pulmonary tuberculosis has been placed in an airborne infection isolation room. Which action by the unlicensed assistive personnel (UAP) requires the nurse to intervene?

Accepted Answer

B: Puts on a surgical mask before taking the client's vital signs. Tuberculosis spreads by airborne droplet nuclei that are small enough to stay in the air and pass around the edges of a surgical mask. Anyone entering the room must wear a fit-tested N95 respirator or a powered air-purifying respirator. A surgical mask does not protect the wearer, so the UAP needs to step out and put on the correct respirator.

Question 3

A 52-year-old client is admitted after being found in a smoke-filled garage. The client reports a severe headache and nausea and is slow to answer questions. The pulse oximeter reads 99% on room air, and the arterial blood gas shows a carboxyhemoglobin level of 26%. A nursing student says the client's oxygenation must be adequate. Complete the following sentence by choosing from the lists of options. The SpO2 of 99% is [Blank 1] because [Blank 2].

Accepted Answer

Blank 1: falsely high; Blank 2: the oximeter reads carboxyhemoglobin as oxygenated hemoglobin. Carbon monoxide poisoning happens when a person breathes carbon monoxide, a gas with no color or smell that comes from fires, engines, and heaters. Carbon monoxide binds to hemoglobin about 200 times more tightly than oxygen does, forming carboxyhemoglobin. Hemoglobin that is carrying carbon monoxide cannot carry oxygen, so the tissues starve even when the lungs are working.

A standard pulse oximeter shines two wavelengths of light through the finger. Carboxyhemoglobin absorbs light almost the same way oxygenated hemoglobin does, so the oximeter counts it as oxygenated. The number on the screen stays high while a quarter of this client's hemoglobin is carrying no oxygen at all. The headache, nausea and slowed thinking are the brain showing that hypoxia.

The carboxyhemoglobin level comes from a blood sample run on a co-oximeter, and that is the number that guides treatment. The client receives 100% oxygen by nonrebreather mask, or by endotracheal tube if needed, which shortens the time it takes carbon monoxide to leave the hemoglobin.

Question 4

The nurse is caring for a 38-year-old client with untreated HIV infection and a CD4 count of 42 cells/mm3 who is admitted to the intensive care unit with Pneumocystis pneumonia. An arterial blood gas on room air shows a PaO2 of 58 mm Hg. Sulfamethoxazole-trimethoprim IV has been started, and the client has no drug allergies. Which additional prescription should the nurse anticipate?

Accepted Answer

A: Prednisone 40 mg by mouth twice daily for 5 days. Pneumocystis pneumonia is a fungal infection of the lungs that strikes people whose CD4 count has fallen below 200 cells/mm3. It is one of the conditions that defines AIDS. The organism fills the alveoli and triggers intense inflammation, so the client becomes severely hypoxemic, often with a dry cough and fever, and the x-ray shows diffuse infiltrates on both sides.

Sulfamethoxazole-trimethoprim is the drug of choice. When the infection is moderate to severe, defined by a PaO2 under 70 mm Hg on room air, a corticosteroid is added within 72 hours. As the antibiotic kills the organisms, the dying organisms worsen the lung inflammation for the first few days, and the steroid blunts that response. It lowers the risk of respiratory failure and death. The usual course is prednisone 40 mg twice daily for 5 days, then a lower dose tapered to complete 21 days.

Question 5

A client at 32 weeks of gestation with preeclampsia with severe features has received magnesium sulfate 2 g/hr IV, from a premixed bag of 40 g in 1,000 mL, for 10 hours. At 0400 her respiratory rate is 16/min, her patellar reflexes are 2+, and she is alert. Her urine output was 22 mL in the past hour and 18 mL the hour before. Which action should the nurse take?

Accepted Answer

B: Notify the health care provider and request a serum magnesium level. Magnesium sulfate is a medicine given by IV infusion to prevent seizures in a pregnant client with preeclampsia or eclampsia.

Magnesium sulfate is excreted almost entirely by the kidneys. When the urine output falls below 30 mL/hr, the magnesium is not cleared and the serum level rises with every hour the infusion continues. Oliguria is also a sign that preeclampsia is affecting the kidneys.

This client has no signs of toxicity yet. Her reflexes are present, her respiratory rate is above 12/min, and she is alert. That is exactly the time to act, before the level climbs. The nurse reports the low output, requests a serum magnesium level, and expects the provider to reduce or stop the infusion. Most magnesium protocols name a urine output under 30 mL/hr as a finding to report.

Question 6

A 66-year-old client with rheumatoid arthritis is admitted with pneumonia, and the home medications are prescribed on admission. Which prescription should the nurse question?

Accepted Answer

D: Methotrexate 7.5 mg orally once daily. Methotrexate is a medicine that slows the growth of rapidly dividing cells and calms the immune system.

Methotrexate for rheumatoid arthritis is taken once a week, not once a day. The weekly dose is often 7.5 to 25 mg, and a client usually takes it on the same day each week. When it is entered as a daily dose, the client receives seven times the intended amount in a week. That causes bone marrow suppression, mouth ulcers, liver injury, and deaths. Daily methotrexate is one of the classic transcription errors made from a home medication list.

The nurse questions the prescription with the provider before any dose is given. Many providers also hold methotrexate during an active infection, which is one more reason to clarify it before giving it.

Question 7

The nurse in a tuberculosis clinic reviews findings for several clients who have taken rifampin, isoniazid, pyrazinamide, and ethambutol for 4 to 8 weeks. For each finding below, click to specify which medication in the regimen is most likely responsible. Each finding may be linked to more than one medication.

Accepted Answer

Trouble telling red from green, with blurred vision: Ethambutol; ALT 240 units/L with yellow sclerae and nausea: Rifampin, Isoniazid, Pyrazinamide; Burning and numbness of both feet: Isoniazid; Orange-red urine and tears: Rifampin; Sudden, painful, red, swollen great toe with a uric acid of 10.4 mg/dL: Pyrazinamide. Each of the four first-line tuberculosis drugs has its own signature adverse effect, and three of them share one. Rifampin colors body fluids orange-red, which is harmless, and it speeds the breakdown of many other drugs. Isoniazid blocks the use of pyridoxine (vitamin B6) by the nerves, causing a burning, numb peripheral neuropathy that pyridoxine prevents. Pyrazinamide reduces the kidneys' excretion of uric acid, so the level rises and some clients develop gout, classically in the great toe. Ethambutol can inflame the optic nerve, and loss of red-green color discrimination with blurred vision is the first sign, so the drug is withheld and the change reported.

Liver injury is shared. Isoniazid, rifampin and pyrazinamide can all cause hepatitis, so a high ALT with jaundice and nausea leads the health care provider to stop all three until the liver recovers, then restart them one at a time.

Question 8

A client admitted with pneumonia has been afebrile for 48 hours, is taking oral antibiotics and has an oxygen saturation of 96% on room air. The utilization review nurse notes that the client remains in the hospital while awaiting a home oxygen evaluation that is no longer needed. Which action should the utilization review nurse take?

Accepted Answer

B: Contact the health care provider and case manager to plan for discharge. Utilization review checks that the level of care matches the client's needs and that hospital resources are used appropriately. A client who is stable on oral antibiotics and no longer needs oxygen meets discharge criteria. The utilization review nurse communicates with the provider and case manager so that discharge can be planned safely, avoiding unnecessary days and costs.

Question 9

During the morning assessment, a 63-year-old client with chronic obstructive pulmonary disease (COPD) becomes short of breath after walking back from the bathroom. The client grips the bed rail and says, "I can't breathe. I'm going to die." The SpO2 is 90% on 2 L/min, and the respiratory rate is 28/min. Which action should the nurse take?

Accepted Answer

C: Stay with the client and coach slow pursed-lip breathing in a calm, low voice. Dyspnea and anxiety feed each other in COPD. Breathlessness causes fear, fear speeds up the breathing, and fast, shallow breaths trap more air, which makes the dyspnea worse. The nurse breaks the cycle by staying with the client and speaking calmly, which lowers fear, and by coaching pursed-lip breathing: in through the nose, then out slowly through pursed lips for about twice as long as the breath in. Slow exhalation keeps the airways open, lets trapped air out, and slows the rate.

The client's SpO2 is 90% on 2 L/min, which is within the usual target for COPD, so this episode is exertional dyspnea with panic, not a sudden drop in oxygenation. Sitting the client upright, leaning slightly forward with the arms supported, helps as well.

Question 10

A client with right lower lobe pneumonia has an oxygen saturation of 89% on oxygen at 2 L/min by nasal cannula. The client is lying on the right side. The nurse should place the client in which of the following positions to improve oxygenation?

Accepted Answer

C: Left side-lying with the head of the bed raised 30 degrees. Gravity pulls more blood to the lower lung. When the client lies on the side with the healthy lung down, more blood flows past alveoli that are open and full of air, so more oxygen enters the blood. This is often called good lung down.

Here the infection is in the right lower lobe. Lying on the right side sends most of the blood to the lung that is full of exudate, where little gas exchange happens, which is part of why the saturation is low. Turning the client onto the left side matches the blood flow to the healthy lung. Raising the head of the bed also lets the diaphragm drop and the chest expand.

Respiratory practice questions.

A client with suspected pulmonary tuberculosis has been placed in an airborne infection isolation room. Which action by the unlicensed assistive personnel (UAP) requires the nurse to intervene?

A 66-year-old client with rheumatoid arthritis is admitted with pneumonia, and the home medications are prescribed on admission. Which prescription should the nurse question?

A client with right lower lobe pneumonia has an oxygen saturation of 89% on oxygen at 2 L/min by nasal cannula. The client is lying on the right side. The nurse should place the client in which of the following positions to improve oxygenation?

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