NCLEX Practice Exam for Respiratory System 3

EXPLANATION

✔Correct answer:

Mucous membranes. Cyanosis is a bluish discoloration of the skin and mucous membranes due to insufficient oxygenation of the blood (hypoxia). In dark-skinned individuals, detecting cyanosis can be more challenging because melanin pigmentation can mask color changes in the skin. Therefore, the mucous membranes—such as the oral mucosa, conjunctiva, and tongue—are the most reliable areas for assessing cyanosis.

Cyanosis occurs when deoxygenated hemoglobin in the blood reaches levels of 5 g/dL or higher, leading to a bluish hue in tissues with high vascularization. In dark-skinned individuals:

• Skin discoloration may be subtle or not visible, making mucous membranes a better indicator.
• Peripheral cyanosis (caused by poor circulation) may not be as noticeable in the nail beds or extremities.
• Central cyanosis (caused by low arterial oxygen levels) is best observed in the lips, gums, and tongue, which lack significant melanin pigmentation.

Imagine trying to spot blue ink on a dark-colored fabric versus a white napkin. The contrast is much clearer on the napkin, just as cyanosis is easier to detect in mucous membranes than on darker skin.

When assessing for cyanosis in dark-skinned individuals, Nurse Allen should:

• Inspect the oral mucosa, conjunctiva, and tongue for bluish or grayish discoloration.
• Assess for other signs of hypoxia, such as restlessness, confusion, tachypnea, and dyspnea.
• Monitor oxygen saturation (SpO₂) using pulse oximetry, as it provides an objective measure of oxygenation.
• Administer oxygen therapy as needed to improve oxygenation and reduce respiratory distress.
• Document findings and report any worsening cyanosis or respiratory distress to the healthcare provider immediately.

✘Incorrect answer options:

Lips: While lips may show cyanosis, mucous membranes (inside the mouth) are more reliable in dark-skinned individuals, as lip discoloration may be harder to differentiate from natural pigmentation.

Nail beds: Peripheral cyanosis in the nail beds can be difficult to detect in dark-skinned individuals due to increased pigmentation and should not be the primary assessment site.

Earlobes: Earlobes have less vascularization and may not accurately reflect oxygenation status, making them a poor indicator of cyanosis in any skin tone.

EXPLANATION

✔Correct answer:

Engaging diaphragmatic breathing. Chronic bronchitis is a form of chronic obstructive pulmonary disease (COPD) characterized by excess mucus production, airway inflammation, and airflow limitation. This condition makes breathing less efficient, leading to air trapping and increased work of breathing.

Diaphragmatic breathing (also called abdominal breathing) is a beneficial technique because it:

• Promotes efficient oxygen exchange by using the diaphragm rather than accessory chest muscles.
• Reduces air trapping and helps with controlled, deep breathing.
• Decreases dyspnea and work of breathing, leading to better lung expansion and oxygenation.

 How to Perform Diaphragmatic Breathing:  

1. Sit in a relaxed position and place one hand on the abdomen and the other on the chest.
2. Inhale deeply through the nose, focusing on expanding the abdomen while keeping the chest still.
3. Exhale slowly through pursed lips, allowing the abdomen to fall.
4. Repeat this process to promote effective gas exchange and relaxation.

Imagine blowing up a balloon. If you take slow, deep breaths from your abdomen rather than shallow ones from your chest, the balloon (lungs) inflates more fully and efficiently, just like diaphragmatic breathing helps optimize lung function.

Nurses should educate patients with chronic bronchitis on breathing techniques to improve oxygenation and reduce dyspnea.

• Teach diaphragmatic breathing to encourage effective lung expansion.
• Instruct on pursed-lip breathing to slow exhalation and prevent airway collapse.
• Advise avoiding rapid, shallow breathing, which can increase air trapping.
• Encourage smoking cessation if applicable, as smoking worsens chronic bronchitis.
• Promote energy conservation techniques to reduce oxygen demand during activities.

✘Incorrect answer options:

Prolonging inhalation over exhalation: Exhalation should be longer than inhalation, especially in COPD, to allow full expulsion of trapped air. Pursed-lip breathing can help achieve this.

Exhaling through an open mouth: Pursed-lip breathing (exhaling through lips that are slightly pursed) is recommended rather than open-mouth exhalation, as it prevents airway collapse and promotes better gas exchange.

Relying on chest breathing: Chest breathing is inefficient and leads to shallow respirations, increasing the work of breathing. Instead, diaphragmatic breathing should be used to maximize lung expansion and efficiency.

EXPLANATION

✔Correct answer:

Non-rebreather mask. A non-rebreather mask (NRB) is the most effective oxygen delivery method for a patient in acute respiratory distress with low oxygen saturation (SpO₂ 88%). The NRB delivers a high concentration of oxygen (approximately 80–100% at 10–15 L/min) by using a reservoir bag and one-way valves to prevent the inhalation of exhaled carbon dioxide.

Mr. Ellis’s sudden onset of dyspnea and hypoxia suggests significant oxygenation impairment, which could be due to conditions like pulmonary edema, acute COPD exacerbation, or pneumonia. Because his oxygen saturation is below 90%, a high-flow oxygen source is needed to rapidly improve tissue oxygenation and prevent further complications such as hypoxemia-induced organ dysfunction.

Imagine a car running low on gas—it needs a rapid refill to keep going. Similarly, Mr. Ellis’s body is running low on oxygen, and the NRB mask provides the quickest and most efficient oxygen supply to "refill" his oxygen levels.

When using a non-rebreather mask, the nurse should:

• Ensure the reservoir bag is fully inflated before applying the mask to the patient.
• Monitor the patient’s respiratory status and oxygen saturation frequently.
• Assess for signs of oxygen toxicity (e.g., headache, confusion, respiratory depression with prolonged high-flow oxygen use).
• Prepare for further interventions, such as positive pressure ventilation, if the patient does not improve.
• Collaborate with the healthcare team to identify and treat the underlying cause of hypoxia.

✘Incorrect answer options:

Simple mask: A simple mask provides 40–60% oxygen at 6–10 L/min, which may not be sufficient for Mr. Ellis’s acute respiratory distress. The NRB mask is a better option for rapid oxygenation.

Face tent: Face tents are primarily used for patients with facial trauma or burns who cannot tolerate a tight-fitting mask. They deliver less precise oxygen concentrations (around 28–50%), which is inadequate for severe hypoxia.

Nasal cannula: While a nasal cannula is commonly used for mild hypoxia, it delivers only 1–6 L/min (24–44% oxygen), which is insufficient for Mr. Ellis’s critical condition.

EXPLANATION

✔ Correct answer:

Respiratory depression. The most serious complication of epidural analgesia is respiratory depression, which can occur if the anesthetic or opioid used in the epidural spreads too high in the spinal cord, affecting the phrenic nerve (C3-C5) and respiratory centers in the brainstem. This can lead to bradypnea, hypoxia, and potentially respiratory failure, requiring immediate intervention.

Epidural analgesia involves the administration of local anesthetics (e.g., bupivacaine, ropivacaine) and/or opioids (e.g., fentanyl, morphine) into the epidural space to block pain signals. However, excessive drug spread above the thoracic or cervical level can impair respiratory muscles and central respiratory drive, causing severe complications.

Opioids and local anesthetics can depress respiratory function through two mechanisms:

• Direct central nervous system depression (opioids) → decreases the brainstem’s respiratory drive.
• Motor blockade of intercostal muscles and diaphragm (local anesthetics) → weakens breathing effort.

Signs of Respiratory Depression to Monitor:

• Respiratory rate <12 breaths per minute.
• Shallow respirations or apnea.
• Decreased oxygen saturation (<90%) and cyanosis.
• Drowsiness progressing to unresponsiveness.

Imagine a dimmer switch controlling a room’s lighting. If you turn it down too much, the room gets too dark. Similarly, if an epidural’s effects spread too far, it can "dim" the body's ability to breathe properly.

Nurse Martinez should take immediate nursing actions to ensure patient safety and collaborate with the healthcare team if the situation worsens.

• Monitor respiratory rate, depth, and oxygen saturation frequently (at least every hour or more often if needed).
• Assess level of sedation using a standardized sedation scale (e.g., Pasero Opioid-Induced Sedation Scale).
• Ensure the epidural infusion settings are correct and verify that the prescribed medication and dose match the provider’s order.
• Encourage deep breathing exercises and reposition the patient to promote optimal lung expansion.
• Notify the physician or anesthesia provider immediately if respiratory rate decreases significantly, sedation deepens, or oxygen saturation drops persistently.
• Administer oxygen therapy as prescribed and prepare for emergency interventions if necessary.
• Have emergency airway equipment (e.g., bag-valve mask, suction) readily available in case of worsening respiratory status.

✘ Incorrect answer options:

Heightened alertness. Heightened alertness is not a typical complication of epidural analgesia. In fact, opioids used in epidurals often cause sedation, not increased alertness. This symptom would not indicate a serious problem requiring immediate intervention.

Increased heart rate. While an increased heart rate may indicate pain or mild hypotension from epidural-induced vasodilation, it is not the most serious complication. Hypotension from an epidural is common but usually manageable with fluids and vasopressors (which are prescribed and administered per provider orders).

Numbness and tingling of the extremities. Some numbness and tingling in the lower extremities are expected side effects of an epidural due to local anesthetic action. However, if the numbness extends to the upper body, it could signal excessive spread of the anesthetic, requiring monitoring, but it is not as immediately life-threatening as respiratory depression.

EXPLANATION

✔Correct answer:

There is an air leak in the system. A closed chest drainage system is used to remove air, blood, or fluid from the pleural space, helping restore normal lung expansion. The water-seal chamber acts as a one-way valve to prevent air from flowing back into the pleural cavity.

Constant bubbling in the water-seal chamber is not normal and indicates an air leak. This suggests that air is entering the system from an unintended source, which could be due to:

• A loose or disconnected connection.
• A leak in the drainage tubing.
• Air escaping from the pleural space (if a pneumothorax is present but usually intermittent in this case).

To confirm the air leak, Nurse Thompson should clamp the tubing briefly near the patient’s chest:

• If bubbling stops, the leak is inside the patient (e.g., a persistent pneumothorax).
• If bubbling continues, the leak is in the system and requires troubleshooting.

If an air leak is suspected, Nurse Thompson should:

• Check all connections for loose fittings and secure them tightly.
• Inspect the tubing and drainage system for cracks or defects.
• Briefly clamp the tube close to the chest to determine if the leak is from the patient or the system.
• Notify the healthcare provider if a persistent air leak is detected.
• Ensure the chest tube dressing is airtight and intact to prevent external air entry.
• Monitor for signs of respiratory distress, which could indicate worsening pneumothorax or ineffective drainage.

✘Incorrect answer options:

The system is functioning as expected: Intermittent bubbling in the water-seal chamber may be normal for a patient with a pneumothorax, but continuous bubbling suggests an air leak.

The client likely has a pneumothorax: While a pneumothorax can cause intermittent bubbling, continuous bubbling suggests a leak in the system, not just air from the pleural space.

The chest tube may be obstructed: If the tube were obstructed, there would be no bubbling or drainage, and the patient might show signs of respiratory distress.

EXPLANATION

✔Correct answer:

Tidal volume. Tidal volume (TV) refers to the amount of air that is moved in and out of the lungs during a normal, relaxed breath. It is a key parameter in respiratory physiology, reflecting the baseline efficiency of breathing. For an average adult, tidal volume is about 500 mL per breath.

Tidal volume ensures adequate ventilation by supplying fresh oxygen while removing carbon dioxide during each respiratory cycle. If tidal volume decreases, as in pneumonia or restrictive lung disease, gas exchange becomes inefficient, leading to hypoxia and increased work of breathing.

Think of a balloon that you gently squeeze and release with each breath. The amount of air going in and out with a gentle squeeze represents tidal volume—just enough for normal breathing.

Monitoring tidal volume and overall lung function is essential in recovering pneumonia patients. Nurses should:

• Encourage deep breathing exercises and incentive spirometry to prevent atelectasis and improve lung expansion.
• Assess respiratory rate and depth to detect signs of respiratory distress or shallow breathing.
• Promote proper positioning (e.g., high Fowler’s position) to enhance lung expansion.
• Monitor oxygen saturation (SpO₂) to ensure adequate oxygenation.
• Educate the patient on coughing and deep breathing techniques to clear secretions and optimize ventilation.

✘Incorrect answer options:

Total lung capacity (TLC): TLC is the maximum amount of air the lungs can hold after a full inhalation, including residual volume. It is not the volume of a normal breath.

Forced vital capacity (FVC): FVC is the maximum amount of air forcefully exhaled after a deep inhalation. It is measured in pulmonary function tests but does not describe a regular breath.

Residual volume (RV): RV is the amount of air remaining in the lungs after a full exhalation. It prevents lung collapse but is not involved in normal tidal breathing.

EXPLANATION

✔Correct answer:

Erythromycin. Legionnaires' disease is a severe form of pneumonia caused by Legionella pneumophila, a gram-negative bacterium often found in contaminated water sources such as air conditioning systems, hot tubs, and cooling towers. It spreads via inhalation of aerosolized bacteria and presents with flu-like symptoms, including:

• Sudden diarrhea (uncommon in typical pneumonia but common in Legionnaires’ disease).
• Loss of appetite, fatigue, headache, chills, and high fever.
• Cough, often nonproductive or mildly productive.

First-Line Treatment:  

Macrolide antibiotics, such as erythromycin or azithromycin, are the first-line treatment for Legionnaires’ disease. These antibiotics effectively inhibit bacterial protein synthesis, reducing bacterial growth and improving symptoms.

Legionella pneumophila is an intracellular pathogen that infects alveolar macrophages, preventing normal immune responses. Macrolides, particularly erythromycin, have excellent intracellular penetration, making them highly effective against Legionella.

Think of Legionella as a burglar hiding inside a locked house (the alveolar macrophage). Erythromycin works like a locksmith, breaking in and eliminating the intruder directly inside the house.

When administering erythromycin, Nurse Bennett should:

• Monitor for gastrointestinal side effects, such as nausea, vomiting, or diarrhea.
• Assess for QT prolongation, as macrolides can increase the risk of arrhythmias.
• Encourage adequate hydration to prevent dehydration from diarrhea and fever.
• Monitor respiratory status, as Legionnaires’ disease can cause severe pneumonia.
• Educate the patient on completing the full antibiotic course to prevent recurrence.

✘Incorrect answer options:

Rifampin: While rifampin is sometimes used as an adjunct therapy in severe Legionnaires’ disease, it is not a first-line treatment. Rifampin is primarily used to treat tuberculosis and certain bacterial infections.

Amantadine: Amantadine is an antiviral medication used to treat influenza A and Parkinson’s disease. It has no effect against Legionella pneumophila, a bacterial infection.

Amphotericin B: Amphotericin B is an antifungal medication used for systemic fungal infections. Since Legionella is a bacterium, antifungals are ineffective.

EXPLANATION

✔ Correct answer:

Kinking of the ventilator tubing. A high-pressure alarm on a mechanical ventilator is triggered when the ventilator detects increased resistance to airflow, requiring more pressure to deliver breaths. One of the most common causes is kinking of the ventilator tubing, which obstructs airflow and increases airway pressure. Other possible causes include mucus plugging, bronchospasm, coughing, or patient biting on the endotracheal (ET) tube.

In acute respiratory distress syndrome (ARDS), the lungs become stiff and noncompliant due to inflammation, pulmonary edema, and alveolar damage. This already makes ventilation more challenging. If there is an additional obstruction—such as a kinked ventilator tube—the ventilator must work harder to push air into the lungs, leading to an increase in airway pressure and triggering the high-pressure alarm.

Imagine drinking a smoothie through a bent straw. The more the straw is kinked, the harder you have to suck to get the drink. Similarly, when the ventilator tubing is kinked, it has to push harder to deliver air, increasing pressure in the system.

Nurse Alvarez should follow a systematic approach to troubleshoot the ventilator alarm, ensuring Mr. Carter receives adequate ventilation:

• Check for kinks or obstructions in the ventilator tubing and reposition if necessary.
• Assess the patient for signs of distress, such as dyspnea, agitation, or cyanosis.
• Suction the airway if mucus plugging is suspected.
• Assess for bronchospasm and administer bronchodilators if needed.
• Check for patient-ventilator asynchrony (e.g., if the patient is coughing or biting the ET tube).
• Manually ventilate with a bag-valve mask (BVM) if necessary while troubleshooting the issue.
• Notify the respiratory therapist or physician if the issue is unresolved.

✘ Incorrect answer options:

A disconnected ventilator tube. A disconnected tube would cause a low-pressure alarm, not a high-pressure alarm, because the ventilator is unable to deliver the set pressure. This results in an air leak rather than increased resistance.

An ET cuff leak. A leak in the endotracheal tube cuff would also trigger a low-pressure alarm, as air would escape instead of reaching the lungs. This leads to ineffective ventilation rather than increased pressure.

A change in the oxygen concentration without resetting the oxygen level alarm. While changes in FiO₂ (fraction of inspired oxygen) can trigger an oxygen concentration alarm, they do not affect airway resistance or pressure. Therefore, this would not be responsible for a high-pressure alarm.

EXPLANATION

✔Correct answer:

The skin test cannot distinguish between an active or dormant tuberculosis infection. The Mantoux tuberculin skin test (TST) is used to detect prior exposure to Mycobacterium tuberculosis. However, it does not differentiate between active tuberculosis (TB) and latent TB infection (LTBI)—it only indicates that the immune system has been sensitized to the bacteria.

How the Test Works:

• A purified protein derivative (PPD) is injected intradermally.
• After 48–72 hours, the test is evaluated based on the size of induration (not redness).
• A positive result suggests prior TB exposure, but further tests (chest X-ray, sputum culture) are needed to determine active disease.

A fire alarm going off doesn’t tell you whether there’s an active fire or if it was triggered by smoke from a burnt meal. Similarly, a positive Mantoux test indicates TB exposure but doesn’t confirm active infection.

Nurse Miller should educate Mr. Patel on the test's interpretation and next steps:

• Explain that induration (raised area), not redness, is measured to determine test positivity.
• Inform the client that a positive test means TB exposure, but additional tests are required for active disease diagnosis.
• Advise immunocompromised individuals (e.g., HIV patients) that they may have a weakened response to the test, requiring alternative diagnostic methods.
• Reassure clients with prior BCG vaccination that they may have a false-positive reaction.
• Encourage follow-up testing, such as chest X-rays or QuantiFERON-TB Gold blood tests, for confirmation.

✘Incorrect answer options:

The area of redness is measured after 3 days to confirm the presence of tuberculosis: The size of induration (not redness) is measured at 48–72 hours. A positive test does not confirm active TB but only prior exposure.

A wheal appearing at the injection site within 2 days signifies active tuberculosis: The initial wheal forms immediately after injection and is not an indicator of TB. The test is read after 48–72 hours to assess immune response.

Some clients develop a reddened reaction, requiring a repeat test in 3 months: Redness alone is not an indication for retesting. Retesting may be needed if exposure occurred after the initial test or for two-step testing in high-risk populations.

EXPLANATION

✔Correct answer:

A decrease in hearing ability or unusual sounds like ringing in the ears. Streptomycin is an aminoglycoside antibiotic used as a second-line treatment for tuberculosis (TB). A significant adverse effect of aminoglycosides is ototoxicity, which can cause irreversible hearing loss, tinnitus (ringing in the ears), or vestibular dysfunction (dizziness and balance issues). This occurs due to damage to the cochlear and vestibular branches of cranial nerve VIII (vestibulocochlear nerve).

Sarah should immediately notify her healthcare provider if she experiences any hearing loss, ringing in the ears, or balance disturbances, as these symptoms may indicate permanent damage if the drug is continued at the same dosage.

Aminoglycosides, including streptomycin, accumulate in the inner ear and damage the hair cells of the cochlea and vestibular system, leading to sensorineural hearing loss and balance disturbances. Ototoxicity is often dose-dependent and worsens with prolonged use or concurrent nephrotoxicity.

Imagine a microphone picking up distorted sounds because its internal wiring is damaged. Similarly, when streptomycin damages the inner ear structures, the brain receives faulty sound signals, leading to hearing loss or ringing.

To minimize the risk of ototoxicity, Nurse Anderson should:

• Monitor for early signs of hearing loss or tinnitus and report any changes immediately.
• Assess vestibular function, including balance and coordination.
• Encourage audiometric testing (hearing exams) before and during therapy.
• Evaluate for co-existing nephrotoxicity, as kidney dysfunction can increase drug accumulation and toxicity risk.
• Teach the patient to avoid other ototoxic medications, such as loop diuretics (e.g., furosemide) or other aminoglycosides.

✘Incorrect answer options:

Difficulty distinguishing between colors: Streptomycin does not typically affect vision or color perception. Ethambutol, another TB medication, is more commonly associated with optic neuritis, leading to red-green color blindness.

A noticeable increase in urinary frequency: While streptomycin is nephrotoxic, increased urinary frequency is not a hallmark symptom of kidney damage. Instead, nephrotoxicity often presents as decreased urine output, elevated creatinine, and proteinuria.

A sudden increase in appetite: Streptomycin does not stimulate appetite. In contrast, TB itself or other medications like rifampin can cause appetite changes.

EXPLANATION

✔Correct answer:

Use of accessory muscles. The use of accessory muscles (such as the sternocleidomastoid, scalene, and intercostal muscles) indicates increased work of breathing, a hallmark sign of respiratory distress in patients with chronic obstructive pulmonary disease (COPD). Normally, breathing is effortless, relying primarily on the diaphragm. However, when the airways become obstructed and the lungs lose elasticity, patients must recruit additional muscles to breathe effectively.

COPD causes air trapping due to narrowed bronchioles and destruction of alveolar walls. As a result:

• The diaphragm flattens and becomes less effective, forcing the patient to use accessory muscles to expand the chest.
• This leads to visible signs of distress, such as retractions (pulling in of skin around the ribs), nasal flaring, and shoulder elevation with each breath.
• Increased effort to breathe can cause fatigue, hypoxia, and even respiratory failure if not addressed promptly.

Imagine trying to drink a thick milkshake through a narrow straw—you instinctively use more effort and even tense your face muscles. Similarly, when airways are obstructed, a patient must use extra muscles to breathe.

When observing accessory muscle use, Nurse Bennett should:

• Assess respiratory rate and depth for signs of impending respiratory failure.
• Encourage pursed-lip breathing to prolong exhalation and reduce air trapping.
• Provide oxygen therapy as prescribed, being cautious with high-flow oxygen in COPD patients.
• Position the patient in high Fowler’s or tripod position to ease breathing effort.
• Monitor for hypoxia and fatigue, and prepare for possible respiratory support if distress worsens.

✘Incorrect answer options:

Diaphragmatic breathing: This is a controlled breathing technique that improves oxygenation and reduces work of breathing. It is not a sign of distress but rather a therapeutic strategy.

Pursed-lip breathing: COPD patients often use pursed-lip breathing to prolong exhalation and reduce air trapping. This is a compensatory mechanism, not an indication of distress.

Controlled breathing: Controlled breathing (e.g., slow, deep breaths) is a sign of effective self-management, not respiratory distress. It helps optimize gas exchange and reduce dyspnea.

EXPLANATION

✔ Correct answer:

Instructing Mr. Hayes to take several deep breaths. For a sputum specimen to be effective in diagnosing respiratory infections, it must be collected from the lower respiratory tract (lungs and bronchi), not from saliva or the upper airway. Taking several deep breaths before expectoration helps loosen and mobilize secretions, making it easier for the patient to produce a sample that contains pathogens, inflammatory cells, and other diagnostic components.

Best practices for sputum collection include:

1. Encouraging deep breathing and coughing to bring up mucus from the lungs.
2. Collecting the specimen in the morning when secretions are more concentrated.
3. Hydrating adequately beforehand to loosen secretions.
4. Ensuring proper labeling and transport of the specimen to the lab promptly.

Imagine a clogged pipe filled with thick fluid. Just spitting into a cup won’t clear it, but if you flush it with water and force air through (deep breaths and coughing), the deeper fluids come out, making it easier to collect what’s inside.

Proper collection techniques are crucial for accurate diagnosis and effective treatment of respiratory infections.

• Encourage deep breathing and coughing to help mobilize sputum.
• Ensure the patient is well-hydrated to thin secretions.
• Collect the first morning sample when sputum is most concentrated.
• Instruct the patient to avoid food intake before collection to prevent contamination.
• Educate the patient that the specimen must come from the lungs, not just saliva.

✘ Incorrect answer options:

Restricting Mr. Hayes’ fluid intake prior to collection. Fluids help loosen mucus, making it easier to cough up a proper sputum sample. Dehydration can make secretions too thick to collect.

Requesting Mr. Hayes to spit saliva into the collection container. Saliva is not a valid sputum sample; it does not contain deep respiratory secretions needed for accurate diagnosis. A proper sample must come from the lungs or bronchi, not the mouth.

Directing Mr. Hayes to provide the specimen right after a meal. Eating may cause nausea or contamination from food particles, which can interfere with laboratory analysis. The best time for collection is before meals, preferably in the morning.

EXPLANATION

✔ Correct answer:

"You should start feeling relief in about 30 minutes." Codeine is an opioid analgesic that also has antitussive (cough suppressant) properties. When taken orally, codeine is absorbed in the gastrointestinal tract and metabolized in the liver, where it is partially converted into morphine. The onset of action for oral codeine typically occurs within 30 minutes, making it an effective option for managing persistent, nonproductive coughs and mild to moderate pain.

Pharmacokinetics:

• Onset of action: ~30 minutes
• Peak effect: 1-2 hours
• Duration of action: 4-6 hours

Since codeine is a centrally acting cough suppressant, it works by depressing the cough reflex in the medulla oblongata, reducing the frequency and intensity of coughing.

Imagine taking a pain reliever for a headache. Like many other medications, codeine takes about 30 minutes to start working, similar to how common pain relievers begin easing symptoms after ingestion.

Nurse Bennett should educate Mr. Lewis about the effects and potential side effects of codeine, including:

• Instructing the patient to avoid activities requiring alertness (e.g., driving) due to possible drowsiness and dizziness.
• Monitoring for side effects such as constipation, nausea, and respiratory depression, especially in opioid-naïve patients.
• Encouraging adequate hydration and fiber intake to prevent opioid-induced constipation.
• Advising the patient to avoid alcohol or other CNS depressants, which can enhance sedation and respiratory depression.
• Instructing the patient to take the medication as prescribed and not to exceed recommended doses to prevent opioid dependence.

✘ Incorrect answer options:

"The drug typically begins working in about 1 hour." Although peak effects may occur around 1 hour, codeine's onset of action is approximately 30 minutes, making this statement inaccurate.

"It may take around 2.5 hours for the drug to work." This timeframe is too long. While codeine reaches peak plasma concentration within 1-2 hours, the initial effects begin much earlier (within 30 minutes).

"You can expect it to take effect in approximately 4 hours." This statement is incorrect, as 4 hours is closer to the duration of action rather than the onset of effect. By this time, the medication's effects are already wearing off, not just beginning.

EXPLANATION

✔Correct answer:

Clarify the order with the physician before adjusting the rate. Theophylline levels should be maintained between 10–20 mcg/mL for therapeutic effects. Mr. Patel’s current level is 6 mcg/mL, which is subtherapeutic. While an increase in dosage may be needed, adjusting the rate without clarifying the order first could be unsafe. Factors such as renal and hepatic function, concurrent medications, and recent dose adjustments must be considered.

Additionally, aminophylline is a theophylline derivative, and changes in infusion rates require careful calculation. Rapid dose increases can lead to toxicity, which may cause tachycardia, arrhythmias, seizures, or hypotension. Nurse Brooks must clarify the order to confirm the intended titration plan.

Calculation Check:  

Physician’s new order: 0.45 mg/kg/hour

• Mr. Patel’s weight: 79.4 kg
• New dose calculation: 0.45 mg × 79.4 kg = 35.73 mg/hour

Current concentration: 400 mg in 500 mL

• 400 mg ÷ 500 mL = 0.8 mg/mL
• 35.73 mg ÷ 0.8 mg/mL = 44.66 mL/hour

This suggests a rate close to 45 mL/hour would be required, not a drastic change. However, because the physician's rationale for dose adjustment is unclear, verification is necessary before making modifications.

Adjusting medication infusion rates without verifying can be like increasing the speed of a car without knowing the road conditions—there’s a risk of losing control and causing harm.

To ensure patient safety, Nurse Brooks should:

• Verify the physician’s rationale for the dose change before making adjustments.
• Monitor Mr. Patel for signs of theophylline toxicity, such as nausea, restlessness, tachycardia, or seizures.
• Assess renal and hepatic function, as impaired metabolism can increase toxicity risk.
• Review other medications to check for potential drug interactions that affect theophylline clearance.
• Document the discussion with the physician and any changes made to the infusion rate.

✘Incorrect answer options:

Increase the infusion rate to 80 ml/hour: This would deliver 64 mg/hour, which is nearly double the prescribed rate (35.73 mg/hour). Such a drastic increase could lead to toxicity.

Maintain the current infusion rate at 50 ml/hour: While Mr. Patel’s current infusion is subtherapeutic, the new order prescribes a specific adjustment. Simply maintaining the rate ignores the physician’s intention, but adjustment should be done with clarification.

Decrease the infusion rate to 40 ml/hour: A reduction in infusion rate would further lower the theophylline level, worsening the subtherapeutic state rather than correcting it.

EXPLANATION

✔ Correct answer:

Stridor and increasing difficulty breathing. After a bronchoscopy and biopsy, Nurse Kim must closely monitor Mr. Torres for airway compromise, bleeding, and respiratory distress. Stridor and increasing difficulty breathing suggest a serious complication, such as:

• Laryngeal edema or bronchospasm, which can obstruct airflow.
• Tracheal injury, which can cause airway swelling.
• Anaphylactic reaction (in rare cases, if the patient reacts to anesthesia or contrast).

Stridor is a high-pitched, harsh sound heard during inspiration due to partial airway obstruction. This is a medical emergency requiring immediate intervention to secure the airway and prevent respiratory failure.

Imagine breathing through a wide straw (normal airway). If the straw starts narrowing (due to swelling or obstruction), airflow becomes difficult and noisy (stridor). Without intervention, it can completely close, leading to suffocation.

If stridor or respiratory distress occurs post-bronchoscopy, the nurse must act quickly.

• Report to the physician immediately and prepare for possible airway management.
• Monitor oxygen saturation and respiratory rate closely.
• Administer supplemental oxygen as needed.
• Prepare for possible emergency interventions (e.g., nebulized epinephrine, corticosteroids, or intubation).
• Assess for other signs of airway compromise, such as cyanosis or use of accessory muscles.

✘ Incorrect answer options:

Hoarseness and a mild sore throat. These are expected post-bronchoscopy due to mild vocal cord irritation from the scope. Symptoms typically resolve within 24–48 hours.

Blood-tinged sputum in small amounts. A small amount of blood after a biopsy is normal due to minor tissue irritation. However, persistent or large amounts of blood would require immediate attention.

Complaints of thirst and dry mouth. These are likely due to fasting before the procedure or residual effects of anesthesia, which is not an urgent concern. Encouraging oral fluids after the gag reflex returns can help.

EXPLANATION

✔ Correct answer:

pH, 7.25; PaCO₂ 50 mm Hg. Respiratory acidosis occurs when the lungs are unable to adequately remove carbon dioxide (CO₂), leading to increased PaCO₂ levels and a decreased blood pH. The primary characteristic of respiratory acidosis is:

• Decreased pH (< 7.35) → Indicates acidosis.
• Increased PaCO₂ (> 45 mm Hg) → Signifies CO₂ retention, which is the hallmark of respiratory acidosis.

In the selected answer, the pH of 7.25 is below the normal range (7.35–7.45), confirming acidosis. Additionally, the PaCO₂ of 50 mm Hg is above the normal range (35–45 mm Hg), confirming respiratory involvement. This aligns with the expected ABG findings in a patient with respiratory acidosis due to reduced alveolar ventilation, such as in Guillain-Barré syndrome (GBS), which can cause respiratory muscle weakness and hypoventilation.

Imagine a chimney that removes smoke from a fireplace. If the chimney is partially blocked, smoke (CO₂) builds up inside the house (the lungs). This buildup makes the air inside the house (the blood) more acidic, just as CO₂ retention leads to respiratory acidosis.

For clients with Guillain-Barré syndrome and respiratory acidosis, nurses must take the following measures to ensure proper ventilation and prevent respiratory failure:

• Monitor respiratory function (rate, depth, and effort) to assess for worsening muscle weakness.
• Evaluate ABG results regularly to detect worsening CO₂ retention and acidosis.
• Prepare for ventilatory support, including possible intubation if respiratory muscle weakness progresses.
• Encourage deep breathing and coughing exercises to improve ventilation and secretion clearance.
• Administer oxygen therapy cautiously, as excessive O₂ in chronic CO₂ retention may reduce the drive to breathe.

✘ Incorrect answer options:

pH, 5.0; PaCO₂ 30 mm Hg.

• A pH of 5.0 is not compatible with life and is unrealistic in any clinical scenario.
• A PaCO₂ of 30 mm Hg is below normal, which suggests respiratory alkalosis, not respiratory acidosis.

pH, 7.40; PaCO₂ 35 mm Hg.

• A pH of 7.40 is within the normal range and does not indicate acidosis.
• A PaCO₂ of 35 mm Hg is also normal, ruling out respiratory acidosis.

pH, 7.35; PaCO₂ 40 mm Hg.

• A pH of 7.35 is at the lower end of normal, meaning no clear acidosis is present.
• A PaCO₂ of 40 mm Hg is within the normal range, which does not indicate CO₂ retention.

EXPLANATION

✔ Correct answer:

"It relaxes the smooth muscles in your airways to improve breathing." Anhydrous theophylline is a methylxanthine bronchodilator used in the management of chronic obstructive pulmonary disease (COPD) and asthma. Its primary mechanism of action is to relax the smooth muscles of the airways, thereby improving airflow and reducing symptoms of bronchoconstriction.

Pharmacological Mechanism:  

• Theophylline works by inhibiting phosphodiesterase (PDE), an enzyme that breaks down cyclic adenosine monophosphate (cAMP).
• Increased levels of cAMP lead to bronchodilation by relaxing the smooth muscle surrounding the bronchi and bronchioles.
• Additionally, theophylline has mild anti-inflammatory properties and can improve diaphragmatic contractility, which is beneficial in COPD patients with respiratory muscle fatigue.

Imagine your airways as a garden hose. When the muscles around the hose are tight (bronchoconstriction), airflow is restricted. Theophylline acts like a muscle relaxer for the hose, allowing it to expand so water (air) can flow more freely.

Nurse Linda should educate Ms. Thompson on the correct use and potential side effects of theophylline, including:

• Monitoring for signs of theophylline toxicity, such as nausea, vomiting, restlessness, tachycardia, and arrhythmias.
• Emphasizing the importance of regular blood level monitoring to maintain therapeutic levels (typically 10-20 mcg/mL).
• Advising against consuming large amounts of caffeine (e.g., coffee, tea, energy drinks) as it can increase the risk of side effects.
• Instructing the patient to take the medication consistently and avoid sudden discontinuation.
• Educating about potential drug interactions, especially with antibiotics like ciprofloxacin and erythromycin, which can increase theophylline levels.

✘ Incorrect answer options:

"It suppresses the immune response to reduce lung inflammation." This statement describes the mechanism of corticosteroids (e.g., prednisone, fluticasone) rather than theophylline. Theophylline has only mild anti-inflammatory effects and does not act primarily by suppressing the immune response.

"It thins mucus secretions, making it easier to clear your lungs." While improved airflow from bronchodilation may indirectly aid mucus clearance, theophylline itself does not act as a mucolytic. Drugs like guaifenesin or N-acetylcysteine are specifically designed to thin mucus.

"It decreases the sensitivity of your airways to allergens and irritants." This mechanism is characteristic of mast cell stabilizers (e.g., cromolyn sodium) and leukotriene modifiers (e.g., montelukast), which reduce airway hypersensitivity but do not function as bronchodilators like theophylline.

EXPLANATION

✔Correct answer:

Dyspnea. Pulmonary embolism (PE) occurs when a blood clot, usually from the deep veins of the legs (deep vein thrombosis), travels to the lungs and obstructs blood flow. One of the most common and hallmark symptoms of PE is dyspnea (shortness of breath). This occurs due to impaired gas exchange and decreased oxygenation of blood, leading to hypoxia.

When a thrombus lodges in the pulmonary arteries, it blocks blood flow, increasing pulmonary vascular resistance. This results in a mismatch between ventilation and perfusion (V/Q mismatch), causing decreased oxygenation and sudden onset of dyspnea. The body responds with an increased respiratory rate (tachypnea) to compensate for the reduced oxygen supply.

Imagine trying to blow air through a straw that is partially blocked. You will have to breathe harder to get enough air. Similarly, in PE, the lungs struggle to oxygenate blood because blood flow is obstructed, causing difficulty in breathing (dyspnea).

Since dyspnea is a critical symptom of PE, nurses should act promptly to ensure proper oxygenation and prevent complications.

• Administer oxygen therapy as prescribed to improve oxygen saturation.
• Monitor vital signs, especially respiratory rate and oxygen saturation.
• Place the patient in a high Fowler’s position to facilitate lung expansion.
• Prepare for potential anticoagulation therapy, such as heparin or warfarin.
• Educate the patient on preventing deep vein thrombosis (DVT) to reduce the risk of future embolisms.

✘Incorrect answer options:

Bradypnea: Bradypnea refers to abnormally slow breathing. In PE, the opposite occurs—tachypnea (rapid breathing) is more common as the body tries to compensate for reduced oxygenation.

Bradycardia: PE typically leads to tachycardia (increased heart rate) as the heart attempts to pump more oxygenated blood. Bradycardia (slow heart rate) is not a common finding.

Decreased respirations: A patient with PE will have increased respiratory rate (tachypnea), not decreased respirations, as the body attempts to maintain oxygenation.

EXPLANATION

✔ Correct answer:

Inflamed lung tissue. Pneumonia, regardless of its cause—whether bacterial, viral, fungal, or atypical (e.g., mycoplasma pneumonia)—is characterized by inflammation of the lung parenchyma (lung tissue), specifically the alveoli and interstitial spaces. This inflammation leads to fluid accumulation, impaired gas exchange, and respiratory symptoms such as cough, dyspnea, and fever.

• The infectious agent (e.g., Streptococcus pneumoniae in pneumococcal pneumonia or Mycoplasma pneumoniae in atypical pneumonia) triggers an inflammatory immune response in the lungs.
• This response leads to capillary leakage, alveolar filling with exudate, and impaired oxygen exchange, causing hypoxia and respiratory distress.
• Common findings across all types of pneumonia include lung consolidation, crackles or rhonchi on auscultation, and varying degrees of respiratory compromise.

Imagine the lungs as a sponge. When pneumonia develops, the infection causes inflammation, and the alveoli fill with fluid, making it harder for the sponge (lungs) to absorb and release air properly.

Nurse Thompson should focus on supportive care and infection control measures, including:

• Monitoring respiratory status (e.g., oxygen saturation, breath sounds, respiratory effort).
• Administering prescribed antibiotics or antivirals based on the causative agent.
• Encouraging deep breathing and coughing exercises to prevent atelectasis.
• Providing oxygen therapy if the patient exhibits signs of hypoxia.
• Maintaining adequate hydration to loosen respiratory secretions.
• Teaching infection control measures (e.g., hand hygiene, vaccination for pneumonia prevention).

✘ Incorrect answer options:

Sudden onset. While bacterial pneumonia (e.g., pneumococcal pneumonia) often has a sudden onset with high fever, chills, and productive cough, other types, such as viral or atypical pneumonia (e.g., mycoplasma pneumonia), may have a gradual onset with milder symptoms. Thus, this feature is not shared by all types of pneumonia.

Responsiveness to penicillin. Not all types of pneumonia respond to penicillin. While pneumococcal pneumonia is often treated with penicillin or cephalosporins, mycoplasma pneumonia is caused by an atypical bacterium that lacks a cell wall, making it resistant to beta-lactam antibiotics (e.g., penicillin, cephalosporins). Instead, macrolides (e.g., azithromycin) or tetracyclines are used to treat mycoplasmal pneumonia.

Elevated white blood cell (WBC) count. Although bacterial pneumonia typically causes an elevated WBC count (leukocytosis) due to the immune response, viral pneumonia may not always lead to a significant increase in WBCs. In some cases, viral pneumonia can even cause a normal or slightly decreased WBC count, making this an inconsistent feature across all pneumonia types.

EXPLANATION

✔Correct answer:

Auscultating the lungs for bilateral breath sounds. Ensuring correct endotracheal (ET) tube placement is a priority in airway management. The most immediate and practical bedside assessment is auscultation of bilateral breath sounds. Proper ET tube placement ensures effective oxygenation and ventilation, preventing complications such as tube malposition, hypoxia, or aspiration.

An ET tube should be positioned 2–3 cm above the carina (the bifurcation of the trachea). If placed incorrectly, it may:

• Enter the right mainstem bronchus, leading to unilateral breath sounds (absent on the left).
• Be displaced into the esophagus, leading to no breath sounds and abdominal distention due to air entry into the stomach instead of the lungs.
• Cause airway obstruction or aspiration if misplaced.

How to Confirm ET Tube Placement:  

• Auscultate for equal bilateral breath sounds (absence may indicate displacement).
• Observe symmetrical chest rise with ventilation.
• Monitor for end-tidal CO₂ (ETCO₂) changes, as proper placement ensures CO₂ exchange.
• Obtain a chest X-ray (gold standard) to confirm precise placement.

Imagine using a snorkel while swimming—if the snorkel is correctly positioned, you can breathe easily, but if it's misplaced or submerged, you'll struggle for air. Similarly, an endotracheal (ET) tube must be positioned correctly in the trachea to ensure proper airflow; if it slips into one lung or the esophagus, oxygen delivery becomes ineffective, making auscultating breath sounds essential to confirm its placement.

To ensure proper ET tube function, Nurse Roberts should:

• Auscultate breath sounds bilaterally after intubation and regularly thereafter.
• Check for equal chest rise and fall with ventilation.
• Monitor for changes in oxygen saturation (SpO₂) and end-tidal CO₂ (ETCO₂).
• Verify ET tube placement with chest X-ray after intubation and as needed.
• Secure the ET tube properly and monitor for accidental displacement.

✘Incorrect answer options:

Turning the client from side to side every 2 hours: While repositioning prevents complications like pressure ulcers and atelectasis, it does not confirm ET tube placement or effectiveness.

Monitoring serial blood gas values every 4 hours: Arterial blood gases (ABGs) assess oxygenation and ventilation but do not confirm ET tube placement. Misplacement can cause abnormal ABG results, but auscultation provides immediate bedside confirmation.

Providing frequent oral hygiene: Oral care prevents ventilator-associated pneumonia (VAP), but it does not ensure ET tube placement or function.

EXPLANATION

✔ Correct answer:

Albuterol (Proventil). The client is exhibiting signs of severe respiratory distress, likely due to an acute asthma exacerbation or status asthmaticus. The key indicators are tachypnea (44 breaths per minute), wheezing, low oxygen saturation (86%), and persistent symptoms despite initial interventions with oxygen and intravenous corticosteroids (methylprednisolone).

Albuterol is a short-acting beta-2 agonist (SABA) that provides rapid bronchodilation by relaxing the smooth muscles in the airway. It is the first-line medication for acute asthma exacerbations because it works quickly to open the airways and relieve wheezing and respiratory distress.

During an asthma attack, bronchospasm, airway inflammation, and mucus production lead to airway obstruction and hypoxia. Albuterol binds to beta-2 adrenergic receptors in the bronchial smooth muscle, stimulating the sympathetic nervous system and causing bronchodilation. This helps improve oxygenation and reduce the work of breathing.

Imagine trying to breathe through a straw that is being squeezed shut. The tighter it gets, the harder it is to get air through. Albuterol works like releasing the pressure on the straw, allowing air to pass through freely again.

Nurse Collins should closely monitor the client’s response to Albuterol and be prepared for additional interventions if needed.

• Administer Albuterol via nebulizer or metered-dose inhaler (MDI) with a spacer to ensure effective delivery.
• Monitor for tachycardia, tremors, and restlessness, which are common side effects of beta-agonists.
• Assess lung sounds before and after administration to determine improvement in wheezing and airflow.
• Ensure continuous pulse oximetry monitoring to track oxygen saturation changes.
• Prepare for possible additional bronchodilator therapy (e.g., ipratropium) or escalation to noninvasive ventilation if respiratory distress worsens.

✘ Incorrect answer options:

Alprazolam (Xanax).  Alprazolam is a benzodiazepine used for anxiety. While the client appears anxious, this anxiety is likely due to hypoxia and respiratory distress, not a primary anxiety disorder. Giving a sedative could depress the respiratory drive, worsening oxygenation and respiratory failure.

Propranolol (Inderal). Propranolol is a non-selective beta-blocker, which can cause bronchoconstriction by blocking beta-2 receptors in the lungs. This can worsen asthma symptoms and is contraindicated in acute respiratory distress.

Morphine. Morphine is an opioid analgesic that can cause respiratory depression. Administering morphine to a patient with already compromised respiratory status could further decrease respiratory drive, worsening hypoxia and potentially leading to respiratory failure.

EXPLANATION

✔ Correct answer:

Halt the procedure and provide oxygen to Ms. Carter. A decreasing heart rate (bradycardia) during suctioning is a critical sign of vagal nerve stimulation or hypoxia. The vagus nerve (cranial nerve X) can be stimulated when the suction catheter irritates the tracheal mucosa, triggering a parasympathetic response that leads to bradycardia. Additionally, prolonged suctioning can reduce oxygen levels, worsening the situation.

To address this, Nurse Riley should immediately stop suctioning and provide supplemental oxygen to prevent further deterioration of the patient's condition. Ensuring adequate oxygenation before, during, and after suctioning is essential to maintaining hemodynamic stability.

• Suctioning temporarily blocks airflow, which can lead to hypoxia.
• Hypoxia and direct stimulation of the vagus nerve can decrease heart rate (bradycardia).
• Prolonged bradycardia can compromise cardiac output, potentially leading to hypotension and cardiac arrest.

Imagine using a vacuum cleaner on a fragile carpet. If the suction is too strong or prolonged, it can pull and damage the fibers. Similarly, excessive suctioning can overstimulate the vagus nerve and deprive the patient of oxygen, leading to a dangerous drop in heart rate.

To prevent and manage suction-induced bradycardia, the nurse should:

• Stop suctioning immediately if bradycardia or other distress signs occur.
• Provide 100% oxygen via a manual resuscitation bag (Ambu bag) or ventilator as needed.
• Limit suctioning to a maximum of 10 seconds per pass to reduce hypoxia risk.
• Hyperoxygenate the patient before and after suctioning to maintain adequate oxygenation.
• Monitor vital signs continuously, including heart rate and oxygen saturation, during the procedure.
• Assess the patient’s response and modify suctioning techniques if necessary.

✘ Incorrect answer options:

Proceed with suctioning as planned: This is unsafe. Continuing suctioning despite signs of bradycardia can worsen hypoxia and lead to severe complications such as cardiac arrest.

Contact the physician immediately: While notifying the physician may be necessary, the priority is to immediately stop suctioning and provide oxygen to the patient. Delaying action could cause further deterioration.

Confirm suctioning does not exceed 15 seconds: The recommended maximum suction duration is 10 seconds, not 15 seconds. Even if suctioning duration is within limits, if the patient exhibits bradycardia, the procedure must be stopped, and oxygenation must be restored.

EXPLANATION

✔ Correct answer:

It helps prevent early airway collapse. Pursed-lip breathing is a technique commonly taught to patients with emphysema and other forms of chronic obstructive pulmonary disease (COPD). This breathing method involves inhaling slowly through the nose and exhaling through pursed lips, similar to blowing out a candle. The primary goal of pursed-lip breathing is to prolong exhalation and create positive airway pressure, which helps keep the airways open longer and prevents early airway collapse.

In emphysema, the alveoli lose elasticity, and the airways tend to collapse prematurely, especially during exhalation. This leads to air trapping and increased work of breathing. By exhaling through pursed lips, a small amount of positive pressure is generated in the airways, which helps to reduce air trapping and improve oxygen exchange.

Imagine blowing up a balloon and then slowly letting the air out by pinching the opening slightly. This controlled release of air keeps the balloon from collapsing too quickly, just like pursed-lip breathing helps keep the airways open during exhalation.

Nurse Carter should educate Mr. Thompson on proper pursed-lip breathing techniques and its benefits, including:

• Instructing the patient to inhale deeply through the nose for about 2 seconds.
• Encouraging the patient to exhale slowly through pursed lips for at least 4 seconds, making the exhalation twice as long as inhalation.
• Teaching the patient to use pursed-lip breathing during episodes of dyspnea or increased exertion to reduce breathlessness.
• Reassuring the patient that this technique can help promote relaxation and improve ventilation efficiency.
• Encouraging regular practice to make pursed-lip breathing a natural response to breathlessness.

✘ Incorrect answer options:

It increases inspiratory muscle strength. Pursed-lip breathing mainly focuses on prolonging exhalation and maintaining airway patency, rather than strengthening inspiratory muscles. Inspiratory muscle training (IMT) exercises, such as using resistance breathing devices, are more effective for improving muscle strength.

It decreases use of accessory breathing muscles. Although pursed-lip breathing can reduce respiratory effort, it does not directly decrease the use of accessory muscles. Instead, it improves airway stability and gas exchange, which can indirectly reduce the work of breathing. The use of diaphragmatic breathing is more effective in minimizing accessory muscle use.

It prolongs the inspiratory phase of respiration. Pursed-lip breathing is primarily focused on prolonging the expiratory phase, which prevents airway collapse and air trapping. The inspiratory phase remains unchanged or is controlled to maintain an optimal breathing pattern.

EXPLANATION

✔Correct answer:

Chest movements. Respiratory excursion refers to the movement of the chest wall during breathing, which helps assess thoracic expansion and lung function. Nurse Collins evaluates this by placing her hands symmetrically on the lower ribs while the client inhales deeply, noting if both sides expand evenly.

Unequal or reduced chest movement can indicate:

• Pneumothorax (air in the pleural space causing lung collapse).
• Pleural effusion (fluid in the pleural space restricting lung expansion).
• Atelectasis (collapsed alveoli reducing lung expansion).
• Neuromuscular disorders affecting respiratory muscles.

Imagine inflating a balloon—if one side inflates less than the other, there might be a blockage or damage. Similarly, if one side of the chest moves less, it could indicate a lung or pleural issue.

When assessing respiratory excursion, Nurse Collins should:

• Observe for symmetrical chest expansion—asymmetry may indicate lung pathology.
• Palpate for abnormalities, such as decreased movement on one side.
• Correlate findings with breath sounds and percussion to identify potential lung conditions.
• Monitor for signs of respiratory distress, such as tachypnea or cyanosis.
• Report any significant asymmetry or reduced movement to the healthcare provider for further evaluation.

✘Incorrect answer options:

Lung vibrations: Lung vibrations are assessed using tactile fremitus, not respiratory excursion. Fremitus evaluates airflow and lung density by feeling for vibrations while the patient speaks.

Vocal sounds: Vocal sounds (e.g., bronchophony, egophony, whispered pectoriloquy) are assessed via auscultation, not respiratory excursion. These tests help detect lung consolidation in conditions like pneumonia.

Breath sounds: Breath sounds are assessed using stethoscope auscultation, not by observing respiratory excursion. Abnormal sounds like wheezing, crackles, or diminished breath sounds provide clues about airway obstruction, fluid buildup, or lung collapse.

EXPLANATION

✔Correct answer:

5 to 10 seconds. When weaning a patient from a tracheostomy, the process must be gradual to allow adaptation to breathing through the upper airway. Initially, the tracheostomy tube is plugged (capped) for only 5 to 10 seconds to assess tolerance. This brief trial helps determine if the patient can handle the increased airway resistance and adequately use their normal breathing structures.

A patient who has had a tracheostomy for an extended period has been breathing through the tube instead of the upper airway. Sudden occlusion of the tracheostomy tube without gradual adaptation can lead to respiratory distress, airway obstruction, or ineffective clearance of secretions.

The 5–10 second trial allows the nurse to assess:

• Airway patency (whether the upper airway is clear).
• Breathing efficiency (if the patient can inhale and exhale effectively).
• Signs of distress (such as stridor, tachypnea, or oxygen desaturation).

Imagine swimming with a snorkel for a long time and then suddenly removing it—you need to ensure you can breathe comfortably without it before fully relying on normal breathing again. Similarly, tracheostomy patients need a gradual adjustment period.

When performing tracheostomy weaning, Nurse Kelly should:

• Begin with short intervals (5–10 seconds) and gradually increase duration as tolerated.
• Closely monitor for signs of respiratory distress, such as tachypnea, stridor, cyanosis, or anxiety.
• Ensure the patient can effectively clear secretions and maintain adequate oxygenation.
• Gradually increase capping duration over time, working toward complete decannulation.
• Collaborate with respiratory therapists and physicians to determine an individualized weaning plan.

✘Incorrect answer options:

30 to 60 minutes: This is too long for an initial trial. Extended capping occurs only after the patient has demonstrated gradual tolerance over multiple short trials.

1 to 2 hours: Capping for this length of time is done in advanced stages of weaning, not during the initial assessment phase.

10 to 15 minutes: While this may be a goal later in the weaning process, 5–10 seconds is the safest starting point to avoid sudden respiratory distress.

EXPLANATION

✔ Correct answer:

Atelectasis. Atelectasis refers to the collapse of alveoli, leading to reduced gas exchange and impaired oxygenation. In clients with chronic obstructive pulmonary disease (COPD) and a history of myocardial infarction (MI), the risk of atelectasis increases due to factors such as immobility, weakness, and an ineffective cough. Mr. Thompson’s extreme weakness prevents him from clearing secretions effectively, allowing mucus to accumulate and obstruct the airways, promoting alveolar collapse.

When a patient is unable to take deep breaths or cough effectively, mucus builds up in the airways, causing obstruction and preventing air from reaching the alveoli. This leads to alveolar collapse and impaired oxygen exchange, which can contribute to hypoxia and respiratory distress. Atelectasis is particularly concerning in clients with COPD, as their compromised lung function further increases the risk of respiratory failure.

Imagine a group of small balloons (alveoli) that need air to stay inflated. If these balloons get clogged with mucus or are not properly inflated due to weak breaths, they collapse, making it harder for the person to breathe.

To prevent atelectasis, Nurse Martinez should implement strategies to promote lung expansion and secretion clearance. These include:

• Encouraging deep breathing exercises and the use of an incentive spirometer to promote alveolar inflation.
• Implementing chest physiotherapy and postural drainage to mobilize secretions.
• Promoting early ambulation to enhance lung expansion and prevent complications of immobility.
• Encouraging adequate hydration to thin mucus and facilitate expectoration.
• Assessing for signs of respiratory distress, decreased breath sounds, or hypoxia, which may indicate worsening atelectasis.

✘ Incorrect answer options:

Pleural effusion. Pleural effusion is the accumulation of fluid between the pleural layers surrounding the lungs. It is commonly associated with conditions such as heart failure, pneumonia, or malignancies rather than weakness and ineffective cough. While pleural effusion can impair breathing, it is not the most immediate concern for this client.

Pulmonary edema. Pulmonary edema results from fluid accumulation in the alveoli, typically caused by left-sided heart failure or increased pulmonary capillary pressure. Although Mr. Thompson has a history of myocardial infarction, there is no indication that he is experiencing fluid overload or cardiac decompensation, which would lead to pulmonary edema.

Oxygen toxicity. Oxygen toxicity occurs when a patient receives high concentrations of oxygen for prolonged periods, leading to alveolar damage and worsening respiratory function. While COPD patients are sensitive to high oxygen levels, the question does not mention excessive oxygen administration, making this a less relevant concern compared to atelectasis.

EXPLANATION

✔ Correct answer:

10 seconds. When performing tracheal suctioning, it is essential to minimize hypoxia and prevent airway trauma. Suctioning should be applied for no more than 10 seconds at a time to reduce oxygen deprivation, airway irritation, and potential damage to the tracheal mucosa.

The suctioning process temporarily obstructs airflow, leading to a decrease in oxygenation. Prolonged suctioning can cause hypoxia, bradycardia (due to vagal nerve stimulation), and mucosal damage. To minimize these risks, the procedure should be brief, followed by adequate oxygenation before and after suctioning.

Imagine holding your breath while quickly cleaning a clogged vacuum hose. If you hold it for too long, you'll feel short of breath. Similarly, if suctioning lasts too long, it deprives the patient of oxygen, leading to distress.

To ensure patient safety, the following nursing interventions should be followed during suctioning:

• Hyperoxygenate the patient with 100% oxygen for 30-60 seconds before and after suctioning to prevent hypoxia.
• Use sterile technique to minimize the risk of infection.
• Limit each suction pass to a maximum of 10 seconds.
• Allow at least 30-60 seconds between suction passes to let the patient recover.
• Monitor vital signs, including oxygen saturation and heart rate, during and after the procedure.
• Observe for signs of respiratory distress, such as cyanosis or increased work of breathing.

✘ Incorrect answer options:

1 minute: This is far too long and would result in significant hypoxia, potentially causing respiratory distress, bradycardia, or even cardiac arrest.

5 seconds: While brief suctioning is safer, 5 seconds may not be sufficient to effectively remove secretions. The recommended limit is 10 seconds to balance effectiveness and safety.

30 seconds: Suctioning for this duration greatly increases the risk of oxygen deprivation, mucosal damage, and vagal stimulation leading to bradycardia. This is unsafe and not recommended.

EXPLANATION

✔ Correct answer:

Being overweight.  Clients with chronic bronchitis, a form of chronic obstructive pulmonary disease (COPD), experience impaired gas exchange, dyspnea (shortness of breath), and increased work of breathing due to mucus production and airway inflammation. Excess body weight increases the body’s oxygen demands and worsens respiratory function.

• Obesity increases the workload of breathing because excess adipose tissue restricts lung expansion and reduces diaphragmatic movement.
• Excess weight leads to increased metabolic demands, meaning the body needs more oxygen to function, which is problematic for a client already experiencing chronic hypoxia.
• Abdominal obesity can further compress the diaphragm, making it harder to take deep breaths and effectively ventilate the lungs.

In chronic bronchitis, persistent inflammation leads to airway narrowing, mucus plugging, and decreased airflow, making oxygen intake less efficient. If a client is overweight, their oxygen consumption increases because the heart and lungs must work harder to supply oxygen to additional body tissue. This worsens dyspnea, fatigue, and activity intolerance.

Imagine trying to breathe through a straw while carrying a heavy backpack. The heavier the backpack (extra body weight), the harder it is to breathe. This is similar to how excess weight increases oxygen demands in clients with chronic bronchitis.

Nurse Anderson should educate the client on lifestyle changes that can help minimize oxygen demands and improve activity tolerance.

• Encourage gradual weight management through a balanced diet and appropriate exercise within the client’s tolerance.
• Teach energy conservation techniques, such as taking breaks between activities and using assistive devices as needed.
• Promote pursed-lip and diaphragmatic breathing to enhance oxygenation and reduce dyspnea.
• Advise against excessive carbohydrate intake, as carbohydrate metabolism produces more CO2, increasing the respiratory workload.
• Encourage small, frequent meals to prevent post-meal bloating, which can make breathing more difficult.

✘ Incorrect answer options:

Drinking more than 1,500 ml of fluid daily. Adequate hydration is beneficial, not harmful, for clients with chronic bronchitis. Fluids help thin mucus secretions, making it easier to clear the airways. Unless contraindicated by conditions like heart failure, clients are often encouraged to drink at least 2-3 liters per day.

Eating a high-protein snack at bedtime. Protein is essential for maintaining muscle strength, including the respiratory muscles. A high-protein diet is recommended for COPD patients to prevent muscle wasting. As long as it doesn’t cause bloating or acid reflux, a protein snack at bedtime is not problematic.

Eating more than three large meals a day. While large meals can cause abdominal distension and shortness of breath, eating small, frequent meals is actually encouraged in clients with chronic bronchitis. However, meal size rather than meal frequency is the issue, making this answer less correct than obesity in terms of increasing oxygen demand.

EXPLANATION

✔ Correct answer:

Temporary cessation of breathing (apnea). Patients with chronic obstructive pulmonary disease (COPD) often rely on a hypoxic drive to regulate breathing. Unlike healthy individuals, whose breathing is primarily driven by high carbon dioxide (CO₂) levels, patients with COPD may develop chronic CO₂ retention. As a result, their respiratory drive becomes more dependent on low oxygen (hypoxia) rather than high CO₂.

When excessive supplemental oxygen is administered, it can reduce the hypoxic stimulus for breathing, leading to hypoventilation or even temporary apnea (cessation of breathing). This can cause a dangerous increase in CO₂ retention (hypercapnia), leading to respiratory acidosis and respiratory failure.

Imagine a car with a faulty gas gauge that only shows “empty” when the tank is nearly full. If the driver fills the tank too much, the gauge no longer signals when fuel is low, and the car suddenly stops running. Similarly, excessive oxygen in COPD patients can “turn off” their breathing drive, leading to apnea.

To prevent oxygen-induced hypoventilation in COPD patients, nurses should:

• Use low-flow oxygen therapy (1–2 L/min via nasal cannula) to avoid suppressing the hypoxic drive.
• Monitor oxygen saturation (SpO₂) closely, keeping it within the target range of 88–92%.
• Assess for signs of CO₂ retention (e.g., confusion, lethargy, dyspnea, headache, flushed skin).
• Obtain arterial blood gas (ABG) tests as needed to evaluate CO₂ levels and acid-base balance.
• Be prepared for ventilatory support if the patient shows signs of respiratory failure.

✘ Incorrect answer options:

Chest pain related to reduced oxygen supply to the heart. While COPD and coronary artery disease (CAD) both affect oxygenation, excessive oxygen administration in COPD does not directly cause ischemic chest pain. However, hypercapnia and acidosis can increase cardiac workload, which may worsen existing CAD.

An imbalance leading to respiratory alkalosis. Respiratory alkalosis occurs when there is low CO₂ (hypocapnia), usually due to hyperventilation. In COPD patients, excessive oxygen therapy leads to CO₂ retention (hypercapnia), not loss, causing respiratory acidosis, not alkalosis.

A disturbance in acid-base balance causing metabolic acidosis. Metabolic acidosis results from non-respiratory factors, such as kidney disease, diabetic ketoacidosis, or lactic acidosis. Excess oxygen in COPD does not trigger metabolic acidosis; instead, it can cause respiratory acidosis due to CO₂ retention.

EXPLANATION

✔Correct answer:

Clear, hollow resonant sounds. Percussion is an essential technique used by nurses to assess underlying lung structures. Resonant sounds are the normal finding when percussing healthy lung tissue. These sounds are clear, low-pitched, and hollow, indicating that the lungs are filled with air, which is essential for efficient gas exchange.

Normal lung parenchyma contains air-filled alveoli, which allow sound waves to resonate effectively. The thoracic cavity’s elasticity and aeration contribute to the production of a clear, hollow resonance during percussion. If lung tissue becomes consolidated or hyperinflated due to disease, different sounds may be heard instead.

Think of tapping on a balloon versus a pillow. A balloon, which is filled with air, produces a hollow sound when tapped—similar to normal lungs. A pillow, which is dense, absorbs the sound, much like lungs with fluid or solid masses.

Percussion findings help guide further assessment and management. If abnormal sounds are detected, the nurse should take additional steps:

• Compare percussion sounds bilaterally to detect asymmetry.
• Note any dullness or hyperresonance, which may indicate underlying conditions like pneumonia or emphysema.
• Correlate percussion findings with auscultation to confirm abnormal lung sounds (e.g., crackles or wheezing).
• Monitor the patient for respiratory distress, especially in those with conditions like asthma.
• Document and report abnormal findings to the healthcare provider for further evaluation.

✘Incorrect answer options:

Overly loud hyperresonant sounds: Hyperresonance is an abnormally loud, lower-pitched sound heard in conditions like emphysema or pneumothorax, where there is excessive air trapping or air accumulation in the pleural space. This is not a normal lung finding.

Muted, thud-like dull sounds: Dull sounds occur when fluid or solid tissue replaces air-filled lung space, as seen in pneumonia, pleural effusion, or lung tumors. This is not characteristic of normal lungs.

Sharp, soft flat sounds: Flat sounds are very soft and high-pitched, typically heard over bone, muscle, or dense tissue, such as the scapula or thigh. They are not expected over the lungs unless there is extreme consolidation or pleural thickening.