Med-Surg Practice Test #2: Respiratory

Answer: C. Raise the head of the bed, apply oxygen, stay with the client and call the rapid response team or provider.

Rationale: Sudden shortness of breath, pleuritic chest pain, a fast heart rate, fast breathing and low oxygen saturation after hip surgery strongly suggest a pulmonary embolism. Recent orthopedic surgery and reduced mobility are major risk factors. The nurse raises the head of the bed to ease breathing, applies oxygen, stays with the client and gets help right away. The nurse can expect orders for diagnostic imaging such as CT pulmonary angiography and anticoagulation, per the provider and facility protocol. Option A is wrong because coughing and the spirometer do not treat a blocked pulmonary artery and delay care. Option B is wrong because treating the pain and waiting misses a life-threatening emergency. Option D is wrong because walking increases oxygen demand and is unsafe for an unstable client.

Answer: A. Call the rapid response team or provider immediately, give high-flow oxygen, and prepare for emergency needle decompression.

Rationale: Absent breath sounds on one side, a trachea pushed toward the opposite side, distended neck veins and falling blood pressure point to a tension pneumothorax. A needle insertion during central line placement can puncture the lung. Air builds up in the pleural space with no way out, collapses the lung and pushes on the heart and great vessels, which blocks blood return to the heart. This is an emergency: the provider performs needle decompression (or finger thoracostomy) and then a chest tube is placed. Option B is wrong because lying flat worsens breathing and does not fix the cause of the low blood pressure. Option C is wrong because waiting can be fatal. Option D is wrong because rebreathing into a bag lowers oxygen further in a client who is already hypoxic.

Answer: D. Draw the blood cultures (and the sputum sample if it can be collected right away), then start the antibiotic promptly.

Rationale: Cultures are collected before the first antibiotic dose whenever this can be done without a long delay, because even one dose can kill bacteria in the sample and make the culture falsely negative. The antibiotic is then given promptly, since delays in treatment worsen outcomes, especially if sepsis is present. If a sputum sample cannot be obtained quickly, the antibiotic should not be held while waiting for it. Option A is wrong because giving the antibiotic first can make the cultures unreliable. Option B is wrong because culture results take one or more days; treatment starts empirically and is adjusted when results return. Option C is wrong because treating the fever does not treat the infection, and holding the antibiotic is unsafe.

Answer: B. "Breathe in through your nose, then breathe out slowly through pursed lips, taking about twice as long to breathe out as you did to breathe in."

Rationale: In COPD, small airways collapse during exhalation and air gets trapped in the lungs. Pursed-lip breathing creates slight back pressure that keeps the airways open longer, lets more trapped air out, slows the breathing rate and reduces the feeling of breathlessness. Sitting and leaning forward with the arms supported (tripod position) also helps. Option A is wrong because rapid, shallow breathing traps more air and increases the work of breathing. Option C is wrong because breath-holding raises carbon dioxide and worsens breathlessness. Option D is wrong because lying flat lets the abdominal contents push up on the diaphragm and makes breathing harder.

Answer: C. The new nurse applies suction while inserting the catheter and keeps it on for about 30 seconds.

Rationale: Suction should be applied only while the catheter is being withdrawn, and each pass should be short; most policies limit a pass to about 10 to 15 seconds. Suctioning while inserting, or for a long time, removes oxygen from the airway along with the secretions and can cause hypoxemia, bradycardia, airway trauma and atelectasis. The nurse should stop the new nurse, let the client recover and reoxygenate, and review the technique. Option A is correct practice because preoxygenation reduces suction-related hypoxemia. Option B is correct practice because sterile technique is used for tracheal suctioning in the hospital. Option D is correct practice because suction is applied on withdrawal only.

Answer: A. New shortness of breath, SpO2 down from 95% to 87%, and diminished breath sounds on the right

Rationale: A thoracentesis needle can puncture the lung and cause a pneumothorax. New shortness of breath, falling oxygen saturation and decreased breath sounds on the procedure side need immediate reporting; a chest x-ray is often done after the procedure to check for this. Removing a large amount of fluid can also cause re-expansion pulmonary edema, which presents with coughing, chest tightness and worsening breathing. Option B is wrong because a dry dressing is expected. Option C is wrong because mild soreness at the site is common and is managed with comfort measures. Option D is wrong because easier breathing is the goal of draining the fluid.

Answer: D. Check the system from the insertion site to the drainage unit for an air leak, such as a loose connection, and notify the provider if the leak continues.

Rationale: With a pneumothorax, some intermittent bubbling in the water-seal chamber when the client exhales or coughs can be expected while air leaves the pleural space. Continuous bubbling suggests an air leak in the system, such as a loose connection, a cracked unit or a tube that has pulled partway out. The nurse checks the dressing, insertion site and every connection, tightens any loose ones, and reports a leak that cannot be found or fixed. Option A is wrong because leaving a tube clamped can trap air and cause a tension pneumothorax; brief clamping to locate a leak is done only if facility policy and the provider allow it. Option B is wrong because stripping creates high negative pressure and is not routinely done; it does not fix an air leak. Option C is wrong because the wall suction setting does not stop a leak, and suction is set to the level the provider orders.

Answer: B. "I'll breathe out normally, seal my lips around the mouthpiece, breathe in slowly and deeply, and then hold my breath for a few seconds."

Rationale: An incentive spirometer encourages slow, deep breaths that open small airways and alveoli and help prevent atelectasis and pneumonia after surgery. The client breathes out normally, seals the lips around the mouthpiece, inhales slowly and deeply, holds the breath for a few seconds if able, and then exhales. It is used often while awake, commonly about 10 breaths every hour, as the provider or facility orders, along with coughing and early walking. Splinting the incision with a pillow makes this more comfortable. Option A is wrong because the device is used by breathing in, not blowing out. Option C is wrong because once a day is not enough to prevent atelectasis. Option D is wrong because fast breaths do not fill the lungs as well as slow, sustained breaths.

Answer: A. Check the client and the ventilator circuit for a disconnection or cuff leak; if the cause cannot be found quickly, ventilate with a manual resuscitation bag and call the respiratory therapist.

Rationale: A low-pressure or low-volume alarm means the ventilator is not delivering or receiving the expected breath, most often because the circuit has come apart, the tube has moved, or the cuff is leaking. The nurse goes to the client first, checks the tubing from the client to the ventilator, and reconnects anything loose. If the problem cannot be found and fixed quickly, the nurse disconnects the client from the ventilator and gives breaths with a manual resuscitation bag attached to oxygen while getting help. Option B is wrong because the nurse never silences an alarm without checking the client. Options C and D are wrong because secretions and biting the tube cause high-pressure alarms, not low-pressure alarms.

Answer: C. "Use your quick-relief inhaler as your plan directs and get emergency care now; call 911 if you can't walk or talk easily or your lips or fingernails look blue."

Rationale: Most asthma action plans place a peak flow below 50% of personal best in the red (medical alert) zone, especially when quick-relief medicine has not helped and the client cannot speak in full sentences. This is a severe attack that needs emergency care now; the client follows the red-zone steps on their own plan, which the provider sets. Option A is wrong because a controller inhaler is for long-term control and does not relieve an acute attack. Option B is wrong because this reading is not a caution (yellow zone) reading, and waiting until tomorrow is dangerous. Option D is wrong because rest and fluids do not treat severe airway narrowing.