ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 19 : Introduction to the Respiratory System Questions
Question 1 of 5
The nurse is caring for clients on the neurological unit. Which triad of neurological mechanisms does the nurse identify as most responsible when there is abnormality in ventilation control?
Correct Answer: D
Rationale: Several mechanisms control ventilation. The respiratory center in the medulla oblongata and pons control rate and depth of respirations. The central chemoreceptors in the medulla and peripheral chemoreceptors in the aortic arch also provide a mechanism for detecting abnormalities and signal changes to alter the pH and levels of oxygen in the blood. The other options have an incorrect piece of the triad.
Question 2 of 5
The nurse is caring for a client with a decrease in airway diameter causing airway resistance. The client experiences coughing and mucus production. On lung assessment, which adventitious breath sounds are anticipated?
Correct Answer: D
Rationale: A decrease in airway diameter, such as in asthma, produces breath sounds of wheezes. Wheezes may be sibilant (hissing or whistling) or sonorous (full and deep). Sibilant wheezes (formerly called wheezes) are continuous musical sounds that can be heard during inspiration and expiration. They result from air passing through narrowed or partially obstructed air passages and are heard in clients with increased secretions. Sonorous wheezes (formerly called rhonchi) are lower pitched and are heard in the trachea and bronchi. Sonorous wheezes are coarse, rattling sounds similar to snoring usually caused by secretion in the bronchial tree. Crackles, also called rales, are crackling or rattling sounds signifying fluid or exudate in the lung fields. Rubs are secretions that can be heard in the large airway.
Question 3 of 5
The client is returning from the operating room following a bronchoscopy. Which action, performed by the nursing assistant, would the nurse stop if began prior to nursing assessment?
Correct Answer: C
Rationale: When completing a procedure which sends a scope down the throat, the gag reflex is anesthetized to reduce discomfort. Upon returning to the nursing unit, the gag reflex must be assessed before providing any food or fluids to the client. The client may need assistance following the procedure for activity and ambulation but this is not restricted in the post-procedure period.
Question 4 of 5
The student nurse is learning breath sounds while listening to a client in the physician's office. An experienced nurse is assisting and notes air movement over the trachea to the upper lungs. The air movement is noted equally on inspiration and expiration. Which breath sounds would the nurse document?
Correct Answer: C
Rationale: Air movement over the trachea and upper lungs is a normal finding for bronchovesicular sounds. The air movement is noted equally on inspiration and expiration. The other choices do not match the description.
Question 5 of 5
The nurse is caring for a client whose respiratory status has declined since shift report. The client has tachypnea, is restless, and displays cyanosis. Which diagnostic test should the nurse perform first?
Correct Answer: C
Rationale: Pulse oximetry is a noninvasive method to determine arterial oxygen saturation. Normal values are 95% and above. Using this diagnostic test first provides rapid information of the client's respiratory system. All other options vary in amount of time and patient participation in determining further information regarding the respiratory system.