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Respiratory Emergencies CEN Practice Questions - CEN Questions On Respiratory Emergencies
Question 1.
An unrestrained {passenger is thrown 20 feet (6 m) from a car that hit an embankment. On arrival to the emergency department, the patient is conscious and complains of shortness of breath. His vital signs are blood pressure 108/66 mm Hg, pulse 116 beats/ minute with weak radial pulses, and respirations 26 breaths/minute and shallow. Capillary refill is delayed. The lungs are clear bilaterally with diminished breath sounds on the right. Paradoxical chest movement is noted on the right side. A chest radiograph shows a right pneumothorax and multiple rib fractures on the right (fourth to seventh). Which of the following potential injuries would be the trauma nurse’s primary concern for this patient?
(a) Flail chest
(b) Tension pneumothorax
(c) Ruptured diaphragm
(d) Massive hemothorax
Answer:
(a) Flail chest
Rationale:
Fail chest is caused by two or more frac¬tures of two to three or more adjacent ribs. These fractures do not move with the chest wall during respiration. Signs include paradoxical movement of the chest wall during inspiration and expiration, ineffective ventilation, and dyspnea. Although flail chest can also cause a tension pneumothorax, this is not the primary concern for the trauma nurse.
Classic signs of a tension pneumothorax include tracheal deviation, cyanosis, severe dyspnea, absent breath sounds on the affected side, distended jugular veins, and shock. The patient with a ruptured diaphragm will present with hypotension, dyspnea, dysphagia, shifted heart sounds, and bowel sounds in the lower to middle chest. A patient with a massive hemothorax will show signs of shock (tachycardia and hypotension), dullness on percussion on the injured side, decreased breath sounds on the injured side, respiratory distress and, possibly, a mediastinal shift.
Flail chest leads to an inability to ventilate. In order to correct this, apply positive pressure ventilation—that is, intubation!
Question 2.
Which of the following assessment findings would NOT indicate a flail chest?
(a) Paradoxical movement
(b) Sucking chest wound
(c) Respiratory distress
(d) Pulmonary contusion
Answer:
(b)Sucking chest wound
Rationale:
A sucking chest wound is indicative of an open pneumothorax. All other findings are associated with flail chest.
Although paradoxical movement of the chest wall is always the clue for flail chest, patients in the early phases of their trauma situation may not always demonstrate this phenomenon due to muscle spasms and splinting due to pain. Once pain control is administered, the flail segment will be more readily seen to move in a paradoxical fashion.
Question 3.
Which of the following drugs is safe for administration to the patient with asthma?
(a) Beta-adrenergic blockers
(b) Beta2-agonists
(c) Salicylates (Aspirin)
(d) Nonsteroidal anti-inflammatory drugs (NSAIDs)
Answer:
(b) Beta2-agonists
Rationale:
Beta2-agonists are the first-line drugs of choice for the patient with asthma. They relax bronchial smooth muscle and enhance mucociliary clearance. Beta-adrenergic blockers, salicylates (Aspirin), and NSAIDs can all worsen asthma.
Question 4.
Which of the following findings is NOT consistent with blood loss greater than 1,500 mL in a patient with a hemothorax?
(a) Mediastinal shift
(b) Systolic blood pressure less than 80 mm Hg
(c) Capillary refill greater than 4 seconds
(d) Increased urinary output
Answer:
(d) Increased urinary output
Rationale:
The patient with a massive hemothorax will exhibit decreased urinary output due to decreased per-fusion. A mediastinal shift, systolic blood pressure less than 80 mm Hg, and a capillary refill greater than 4 seconds can all be associated with a hemothorax greater than 1,500 mL
Question 5.
After teaching the patient with asthma about inhalers, which of the following statements indicates the need for further instruction?
(a) “I should hold the inhaler upright and shake it well.”
(b) "I should hold my breath for 5 to 10 seconds after each puff.” '
(c) “I should hold the inhaler in my mouth with a good seal.”
(d) “I should hold my head back and forcefully exhale.”
Answer:
(d) “I should hold my head back and forcefully exhale.”
Rationale:
A forced exhalation is not recom'mended during inhaler use because coughing, small-airway closure, and air trapping may result. The correct tech-nique for using an inhaler is as follows: The inhaler, must be held upright and shook to ensure it is mixed thoroughly before administration. After inhalation of the medication, the patient should then hold his/her breatb, for 5 to 10 seconds to allow the medication to reach' as far as possible into the lungs. If the patient has difficulty with this technique, a spacer device may be added to the inhaler. A good seal should also be part of the process.
A spacer can be used to assist patients with using inhalers. A spacer provides a “space” for the medica-tion to rest before being inhaled, leading to easier inhaler use. Spacers also mean less of the medication gets deposited into the mouth and throat, where it can lead to irritation.
Question 6.
The first priority for a patient with a pulmonary embolus (PE) is:
(a) Correcting the hypoxia with oxygen.
(b) Administering heparin.
(c) Considering thrombolytic therapy.
(d) Administering morphine to treat pain.
Answer:
(a) Correcting the hypoxia with oxygen.
Rationale:
Although all answers are’ appropriate inter-ventions for the patient with a pulmonary embolus (PE), the priority is always airway, breathing, and circulation. Providing high-flow oxygen by simple mask or non-rebreather will increase oxygenation. When treating a PE, a loading dose of heparin should be administered, followed by a continuous drip. The heparin should be titrated to an activated partial thromboplastin time (PTT) IV2 to 2 times the control.
Heparin therapy is sufficient treatment for most patients with pulmonary emboli. For patients who present with significant hemodynamic compromise, streptokinase (Streptase) and tissue plasminogen acti¬vator (alteplase [Activase]) have been approved for use in pulmonary emboli. Pain increases oxygen demand and anxiety and should be treated with an appropriate dose of pain medication such as morphine.
Question 7.
Which of the following is NOT an appropriate intervention for the child with suspected epiglottitis?
(a) Obtaining a throat culture
(b) Providing supplemental oxygen
(c) No invasive procedures
(d) Lateral neck radiograph
Answer:
(a) Obtaining a throat culture
Rationale:
Obtaining a throat culture can lead to in-creased airway obstruction due to initiation of epiglot- •" tic spasm when irritated with the swab and, as such, would not be an appropriate intervention. Epiglottitis is a true medical emergency due to the abrupt inflamma¬tion of the epiglottis causing airway obstruction. A lateral neck radiograph may indicate epiglottic and aryepiglottic swelling, referred to as the “thumbprint sign” and the “posterior triangle. ” The treatment goal is to maintain the airway until surgical capability in the operating room (OR) is possible. This is accomplished by providing supplemental oxygen as tolerated and performing no in-vasive procedures until the airway is secure.
Question 8.
Which of the following statements is NOT true regarding respiratory anatomical and physiologic differences in the pediatric patient?
(a) The diaphragm is flatter and is the primary muscle for ventilation.
(b) Pediatric alveoli are larger and result in increased surface area for gas exchange.
(c) Abdominal muscles play a larger role in respiration.
(d) Children have faster and deeper respiratory rates.
Answer:
(b) Pediatric alveoli are larger and result in increased surface area for gas exchange.
Rationale:
Pediatric patients’ alveoli are smaller than those of an adult and result in decreased surface area for gas exchange. Pediatric patients also have increased respira¬tory rates which deplete limited reserves resulting in sudden decompensation. A pediatric patient’s flatter diaphragm is the primary muscle for ventilation and their abdominal muscles play a larger role in respiration, meaning that ab¬dominal trauma can impact a child’s respiratory status.
Question 9.
Which of the following is the priority intervention for a child with epiglottitis?
(a) QuestionProviding oxygen by nasal cannula
(b) Administering antibiotics
(c) Assisting with intubation
(d) Monitoring for dysrhythmias
Answer:
(c) Assisting with intubation
Rationale:
Because children are at high risk for devel-oping abrupt airway obstruction, the most important intervention for a child with epiglottitis is airway management. Intubation should be performed as soon as possible in a controlled environment. Chil¬dren need supplemental oxygen, but most are so anxious that they will not allow nasal cannula to stay in place. Provide humidified “blow-by” oxygen adminis¬tered by the parent, if possible. The child needs antibiotics; however, the priority is airway management. The most common rhythm in this patient is sinus tachycardia related to compensation and, although important, cardiac monitoring is not a priority.
Patients—whether pediatric or adult—are never discharged with a diagnosis of epiglottitis! And yes, more adults are now being diagnosed with this disease due to childhood vaccinations.
Question 10.
Which of the following is the most serious injury associated with a fracturfe of the first or second rib?
(a) Cervical spine injury
(b) Aortic rupture
(c) Tracheal tear
(d) Clavicular fracture
Answer:
(b) Aortic rupture
Rationale:
Although a cervical spine injury, tracheal tear, or clavicular fracture can be associated with a fracture of the first or second rib, the most serious injury is aortic rupture, which often results in immediate death from severe hemodynamic compromise. Suspect an aortic rupture in a trauma patient with motor, sensory, or pulse deficits in the lower extremities. Such deficits usually result from disruption of blood flow to the spinal cord. Other-symptoms include unexplained hypotension and chest or back pain.
A cervical spine injury can also be serious, especially if it involves a C3, C4, or higher lesion, which can result in respiratory depression. Tracheal tears lead to pneumomediastinum and have the potential for tension pneumothorax if undetected. Clavicular fractures cause great pain; however, they seldom cause more severe consequences.
Question 11.
A 24-year-old patient is in the early stage of an acute asthma attack. Knowing the pathology of asthma and the progression of an asthma attack and its correlation with arterial blood gases (ABGs), the nurse anticipates which of the following ABG results on this patient?
(a) Normal pH, normal PaC02, and normal Pa02
(b) Elevated pH, decreased PaC02, and decreased Pa02
(c) Decreased pH, increased PaC02, and decreased Pa02
(d) Normal pH, normal PaC02, and decreased Pa02
Answer:
(b) Elevated pH, decreased PaC02, and decreased Pa02
Rationale:
Early in an acute asthma attack; respiratory alkalosis should be present, which should be evident with a pH greater than 7.45 and a decreased PaC02 (hypocar- bia) because the carbon dioxide is being blown off at an increased rate. A low Pa02 (hypoxemia) should be present if a true asthmatic event is occurring. Acidosis indicated by a decreased pH (lower than 7.35) would be present in a pa¬tient with hypoventilation, which wbuld be demonstrated by an increased PaC02. Normal readings on the arterial blood gas report would not indicate an asthma attack.
Question 12.
Which common laboratory test is used to assess for congestive heart failure?
(a) Brain natriuretic peptide (BNP)
(b) D-Dimer
(c) Basic metabolic panel (BMP)
(d) Troponin
Answer:
(a) Brain natriuretic peptide (BNP)
Rationale:
Brain naturetic peptide (BNP) is secreted in the ventricles in response to changes in pressure that occur when heart failure occurs and worsens. A
D-dimer is a nonspecific laboratory test to assess for the possibility of an embolus. A basic metabolic panel (BMP) will not assess for heart failure. The troponin T is a cardiac enzyme that assesses heart damage during a myocardial infarction.
Question 13.
An unrestrained patient who was involved in a high-speed motor vehicle collision is brought to the emergency department complaining of chest pain. The paramedic states that there was extensive damage to the steering column. Assessment of the patient’s chest reveals a possible flail chest on the right side. The emergency nurse’s knowledge of flail chest helps her/him understand that the patient is at risk for which of the following?
(a) Myocardial contusion
(b) Pneumonia
(c) Rupture of the great vessels
(d)Pulmonary contusions
Answer:
(b) Pneumonia
Rationale:
A pulmonary contusion is a common re¬sult of nonpenetrating chest trauma, especially flail chest. A myocardial contusion as well as rupture of the great vessels would be considered had the injury been on the left side. Alto, rupture of the great vessels would lead to rapid cardiovascular instability and de¬cline. Pneumonia would not be a direct result of chest trauma.
Question 14.
A patient is brought to the emergency department with mild respiratory distress. His oxygen saturation
is 95 % on 3 liters of oxygen via nasal cannula, his respiratory rate is 28 breaths/minute, and his temperature is 101° F (38.3° C). He has decreased breath sounds over the base of the right lung and complains of a nonproductive cough. He has a history of tuberculosis. Based on these assessment findings, which of the following should the emergency nurse suspect?
(a) Empyema
(b) Transudative effusion
(c) Exudative effusion
(d) Pulmonary embolus
Answer:
(a) Empyema
Rationale:
An empyema contains pus and can be caused by tuberculosis. Transudative effusion is common with heart failure, renal, and liver disease, and exudative effusions are secondary to pulmonary malignancies, pulmonary embolus, and GI disease. Patients with pulmonary embolus often present with hypoxia and tachycardia and are afebrile. If empyemas are not drained, they can solidify causing misdiagnoses via chest radiographs in the future.
Question 15.
A patient with a previous medical history of stroke is brought to the emergency department with altered mental status. The patient’s baseline mental status is alert and oriented to person, place, time, and event; however, at this time, the patient is responsive to painful stimuli only. Examination reveals hot, moist skin with a tympanic temperature of 102.2° F (39° C), adventitious lung sounds, and tachycardia. The emergency nurse suspects which of the following as a possible reason for these signs?
(a) Congestive heart failure
(b) Meningitis
(c) Aspiration pneumonia
(d) Stroke
Answer:
(c) Aspiration pneumonia
Rationale:
Because a patient who has had a stroke may be at high risk for aspiration, the combination of warm, moist skin and adventitious lung sounds most likely results from aspiration pneumonia. An acute onset of altered mental status may indicate a new stroke; however, the presence of a fever suggests an infectious process, ruling out congestive heart failure and a stroke. The adventitious lung sounds do not correlate with meningitis.
Question 16.
Which of the following signs and symptoms may indicate that a patient has aspirated fluid?
(a) Crackles and decreased mentation
(b) Wheezing and poor skin turgor
(c) Decreased urinary output and wheezing
(d) Poor skin turgor and crackles
Answer:
(a) Crackles and decreased mentation
Rationale:
Aspirated fluid will enter the alveoli, causing crackles and decreased oxygenation, which in turn may cause altered mentation. Wheezing is an adventitious lung sound caused by airway constriction, not aspiration. Aspiration does not affect urinary output. Skin turgor is a sign of dehydration and is not caused by aspiration.
Question 17.
Which of the following is the best treatment for high-altitude pulmonary edema (HAPE)?
(a) Acclimatization
(b) Antibiotics
(c) Decrease in altitude
(d) No specific treatment exists
Answer:
(c) Decrease in altitude
Rationale:
A decrease in altitude is the best therapy for high-altitude pulmonary edema (HAPE) as it allows the body to initiate “self-correction” of many altitude-related physiologic processes, but acclimatization will rarely be sufficient without adjunctive therapy. Getting “down off the mountain” is the most beneficial treatment option along with providing oxygen to the patient. The mechanisms of HAPE are not borne by bacteria and thus are not treated as pneumonia. There are several treatments that can be used for high-altitude sickness.
Question 18.
Which of the following is NOT a cause -of noncardiac pulmonary edema?
(a) Trauma
(b) Aspiration
(c) High altitude
(d) Pneumothorax
Answer:
(d) Pneumothorax
Rationale:
A pneumothorax would not cause fluid accu-mulation in the pleural space. Trauma may cause rib frac¬tures or thoracic compression, which can rupture alveoli. Aspiration may contribute to a collection of nonendogenous fluids in the alveoli. Sudden movement to a higher altitude may lead to high-altitude pulmonary edema (HAPE).
Question 19.
When deciding interventions for patients exposed to carbon dioxide (C02), ethane, methane, propane, or other fuel gases, the emergency nurse bases her/his interventions on the knowledge that:
(a) These gases bind to hemoglobin and require high-flow oxygen and occasionally hyperbaric treatment.
(b) These gases do not bind to hemoglobin and often only require “fresh air” and supplemental oxygen.
(c) Each of these gases binds to hemoglobin differently and has an individual treatment and antidote.
(d) Exposure to each of these gases has no negative effects on the body and, therefore, requires no treatment.
Answer:
(b) These gases do not bind to hemoglobin and often only require “fresh air” and supplemental oxygen.
Rationale:
Getting the patient to fresh air, out of the source area of the gas, and supplemental oxygen is the treatment needed if the patient is conscious and breathing. Methane, ethane, propane, C02, and other fuel gases do not react or bind to hemoglobin. These gases have the common effect of crowding out oxygen by re-ducing the oxygen percentage of the air that is taken in at high concentrations, essentially suffocating the victim.
Question 20.
A patient has extensive burns to his head, face, neck, and chest with much of his hair, including his eyebrows, burned off from an ignited flammable liquid. He is conscious, breathing, and in significant pain. He is noted to have a mildly hoarse voice. A baseline physical assessment has been completed. The most reliable additional assessment of the patient’s breathing status would include:
(a) Arterial blood gases (ABGs).
(b) Complete blood count (CBC).
(c) Mixed venous blood gases.
(d) Oxygen saturation monitoring.
Answer:
(a) arterial blood gases (ABGs).
Rationale:
Arterial blood gases (ABGs) provide a spe¬cific value for the Pa02, a much more reliable number to ascertain oxygenation status. An oxygen saturation monitor does not differentiate among oxygen, carbon monoxide, or any other toxic substance bound to the hemoglobin. Mixed venous blood gases do not yield as useful information as an ABG. A complete blood count (CBC) will provide the hemoglobin value important in oxygen transport; however, the hemoglobin is usually re-ported in the ABG results.
Question 21.
A patient was involved in a fire inside a backyard shed and sustained deep partial-thickness burns to his face, head, and neck with singed nasal hair. He arrives with a hoarse voice. Which of the following is the priority nursing management for this patient’s airway?
(a) Deliver high-flow oxygen by rebreather mask.
(b) Monitor for increasing hoarseness of voice.
(c) Prepare for emergent intubation.
(d) Obtain equipment for emergency cricothyrotomy.
Answer:
(c) Prepare for emergent intubation.
Rationale:
The priority for inhalation burn injury is to secure the airway with intubation. Burns of the face may indicate burns to the large and small airways. Although they initially appear stable, a burn will quickly swell and loss of the airway can occur rapidly. Waiting for the situa-tion to worsen may delay intubation to the point at which intubation or even emergency cricothyrotomy is very dif-ficult or impossible. Delivery of high-flow oxygen is appro-priate but a rebreather mask does not secure an airway.
Question 22.
Which of the following is another sign of burn inhalation injury besides hoarseness?
(a) Rapid easing of the work of respiration
(b) Carbonaceous or black-tinged sputum
(c) Persistent wet and productive cough
(d) Moist mucous membranes
Answer:
(b) Carbonaceous or black-tinged sputum
Rationale:
Black-tinged (carbonaceous) sputum from smoke generated in the fire is a hallmark sign of inha-lation injury. Respirations may become increasingly diffi-cult as the injury matures. The mucous membranes of the burn-injured patient are commonly dry. The patient may have rales and rhonchi on auscultation, but the cough is dry and generally nonproductive.
Question 23.
A patient has a history of heart failure and has been diagnosed with pneumonia. Audible, adventitious lung sounds are present. Which of the following sounds would the nurse NOT expect to hear?
(a) Stridor
(b) Crackles
(c) Wheezing
(d) Rhonchi
Answer:
(a) Stridor
Rationale:
Stridor is located in the upper airway and is a result of partial obstruction of the larynx or trachea. Crack¬les, wheezing, and rhonchi are all possible with a patient ex¬periencing an exacerbation of heart failure or pneumonia.
Question 24.
Which of the following is NOT a common sign or symptom of a pulmonary embolus (PE)?
(a) Acute respiratory distress
(b) Nonproductive cough
(c) Bradycardia
(d) Sudden chest pain
Answer:
(c) Bradycardia
Rationale:
Tachycardia, not bradycardia, is seen with a pulmonary embolus (PE). Acute respiratory distress, nonproductive cough, and chest pain are all signs and symptoms of a PE.
Question 25.
Which of the following laboratory tests would be the most important for a patient suspected of pneumonia?
(a) D-Dimer
(b) Sputum culture
(c) Blood cultures
(d) Prothrombin time (PT)
Answer:
(c) Blood cultures
Rationale:
Blood cultures are considered the gold standard laboratory test to assess for specificity of organism-causing pneumonia. A sputum culture may be ordered but is not always obtainable. A D-dimer assesses for protein fragments in the blood after blood clots are dissolved by fibrinolysis, and the prothrombin time (PT) assesses for clotting times.
Question 26.
Which of the following findings indicates effective treatment of a tracheobronchial injury?
(a) Respiratory rate of 36 breaths/minute
(b) Jugular venous distension (JVD)
(c) Repeat reading on pH of 7.42
(d) Increased pulse pressure
Answer:
(c) Repeat reading on pH of 7.42
Rationale:
Findings consistent with improved status after tracheobronchial injury include vital signs within normal limits including a normal pulse pressure, decreased air leak, improved arterial blood gas (ABG) levels, improved tissue perfusion, and no increase in subcutaneous emphysema. The presence of jugular venous distension (JVD) could suggest a diagnosis con-sistent with a tension pneumothorax, a common compli-cation of tracheobronchial injury.
Question 27.
Emergency medical service transports a 52-year-old patient in respiratory distress. Respiratory rate is 40 breaths/minute, and oxygen saturation is 86% on 10 L of oxygen/minute on a partial-rebreather mask. He cannot speak full sentences and the nurse determines that he has had previous visits to the emergency department because of hypoxemia and hypercarbia. Auscultation reveals wheezing and his secretions are thin and scant. Based on these assessment findings, which of the following is the most likely cause of this patient’s symptoms?
(a) Recurrence of chronic bronchitis
(b) Acute exacerbation of emphysema
(c) Acute exacerbation of asthma
(d) Congestive heart failure
Answer:
(b) Acute exacerbation of emphysema
Rationale:
This patient is having an exacerbation of emphysema. The hallmark pathophysiology of emphy-sema and chronic bronchitis is hypoxemia and hypercar- bia. Secretions, particularly thick secretions, are noted in a patient with chronic bronchitis, not emphysema. Emphysemic patients tend to have wheezing, whereas the chronic bronchitis patient usually exhibits rhonchi. White or pink, blood-tinged phlegm or frothy secretions are more indicative of heart failure. An acute episode of asthma is usually associated with hypocarbia as they are breathing rapidly and blowing off the carbon dioxide.
Question 28.
Which of the following is the initial treatment for a patient with a tracheobronchial injury?
(a) Suctioning to maintain airway patency
(b) Preparing for chest tube insertion
(c) Intubating and providing mechanical ventilation
(d) Preparing for surgical intervention
Answer:
(a) Suctioning to maintain airway patency
Rationale:
The priority intervention is to maintain airway patency, which is accomplished by immediate suctioning. Chest tube insertion and surgical intervention will be necessary after the patient is stabilized. If the pa-tient is intubated, the end of the endotracheal tube must be positioned distal to the injury. It is also advisable to monitor for possible pneumothorax.
Question 29.
Which of the following arterial blood gas (ABG) readings is correct for the following results? pH: 7.52 pC02: 22 mm Hg HC03: 26 mEq/L Pa02: 92 mm Hg
(a) Respiratory acidosis >
(b) Respiratory alkalosis
(c) Metabolic acidosis
(d) Metabolic alkalosis
Answer:
(b) Respiratory alkalos
Rationale:
Correct interpretation of these blood gas values is respiratory alkalosis.
Question 30.
Which of the following is the most likely intervention for a patient with a suspected diaphragmatic rupture?
(a) Needle thoracostomy
(b) Chest tube insertion
(c) Preparation for surgery
(d) Transfer to unit for observation
Answer:
(c) Preparation for surgery
Rationale:
Preparing a patient for surgical repair is the most important intervention for a ruptured diaphragm.
Needle thoracostomy and chest tube insertion are contra¬indicated in this patient because of the risk of puncturing the bowel and releasing its contents into the chest cavity. The being within normal limits. Also, the pH and the respiratory components are op¬posite each other, that is, the pH is “up” and the C02 is “down.” This meets criteria for a diagnosis of respiratory alkalosis. A common problem that creates this blood gas reading is hyperventilation. Metabolic problems are directly related to each other; thus, a metabolic alkalosis would show an increase in both the pH and the HC03. The Pa02 is normal.
Question 31.
Which of the following is the treatment of choice for a patient with a pneumothorax?
(a) Chest tube insertion
(b) Emergency thoracotomy
(c) Needle thoracostomy
(d) Emergent intubation
Answer:
(a) Chest tube insertion
Rationale:
A pneumothorax is treated with the inser¬tion of a chest tube connected to an underwater seal the tube remains in place until reexpansion of the lung is achieved. An emergency thoracotomy is reserved for a hemodynamically unstable patient. Needle thoracostomy is used in the treatment of tension pneumothorax. Most patients with a pneumothorax do not require emergent intubation.
Question 32.
Which of the following is the definitive diagnostic study for a patient with suspected esophageal disruption?
(a) Chest radiograph
(b) Transesophageal Echocardiogram
(c) Esophagography
(d) Esophagoscopy
Answer:
(d) Esophagoscopy
Rationale:
The most definitive study is an esopha- goscopy, used in a patient who has a negative esophagogram but is suspected of having esophageal disruption. Chest radiographs often show mediastinal widening, which also occurs in aortic and tracheobronchial ruptures. Esophageal rupture is one of the possible complications of a transesophageal echocardiogram.
Question 33.
A patient with an open pneumothorax is admitted to the emergency department. A nonporous dressing was placed in the field. Which of the following findings suggests worsening of this patient’s condition?
(a) Respiratory rate of 24 breaths/minute
(b) Decreased breath sounds on the affected side
(c) Tracheal shift with jugular venous distension (JVD)
(d) Blood pressure 120/80 mm Hg
Answer:
(c) Tracheal shift with jugular venous distension (JVD)
Rationale:
The finding that suggests a worsening of the patient’s condition is a tracheal shift with jugular ve-nous distension (JVD) which indicates a tension pneu-mothorax. The respiratory rate within normal limits and blood pressure 120/80 mm Hg are acceptable outcomes. The patient will have decreased breath sounds until reex-pansion of the lung has been achieved.
Question 34.
Which of the following is the most appropriate treatment for a stable patient with an open pneumothorax?
(a) Immediate chest tube insertion
(b) Emergency thoracotomy
(c) Autotransfusion
(d) Intravenous dextrose 5 % in water
Answer:
(a) Immediate chest tube insertion
Rationale:
If the patient’s vital signs are stable with no signs of shock, the most appropriate intervention is chest tube insertion for reexpansion of the lung. If
the patient is unstable, an emergency thoracotomy is the definitive therapy. Autotransfusion may be used to stabi¬lize the unstable patient until transportation to surgery. Lactated ringer’s solution and normal saline are the only crystalloids acceptable for administration in traumatic emergencies.
Question 35.
The emergency nurse is caring for a patient who has an endotracheal (ET) tube and is on mechanical ventilation for respiratory failure. The nurse knows that the high-pressure alarm will sound for which of the following reasons?
(a) Obstruction of the circuit tubing
(b) ET tube disconnects from the ventilator
(c) The ET tube becomes displaced
(d) Decreased intrathoracic pressure
Answer:
(a) Obstruction of the circuit tubing
Rationale:
Obstruction of the ventilator circuit tubing will increase expiratory pressure, which will sound the alarm. Other causes of increased expiratory pressure include obstruction of the endotracheal tube (ET) (from biting the endotracheal tube when not properly sedated) or higher intrathoracic pressures. The ET tube becoming disconnected or displaced will result in a lowering pres-sure and would not sound the alarm.
Question 36.
Which of the following is a life-threatening condition that occurs with penetrating chest wounds and results in impaired gas exchange and risk for deficient fluid volume?
(a) Pulmonary contusion
(b) Cardiac contusion
(c) Open pneumothorax
(d) Ruptured esophagus
Answer:
(c) Open pneumothorax
Rationale:
An open pneumothorax, which causes equalization of atmospheric and intrathoracic pres-sures, leads to lung collapse and impaired gas ex-change. A hemothorax is commonly associated with an open pneumothorax and results in a risk of fluid volume deficit. Cardiac and pulmonary contusions usually result from blunt trauma. A ruptured esophagus does have the risk of fluid volume deficit; however, the most serious complications result from infection.
Question 37.
Which of the following findings is consistent with a diagnosis of hyperventilation?
(a) Increased mental acuity
(b) Respiratory acidosis
(c) Left arm pain
(d) Carpopedal spasms
Answer:
(d) Carpopedal spasms
Rationale:
Patients with hyperventilation exhibit car-popedal spasms, anxiety, jaw pain, tachypnea, diffuse chest pain, confusion, diaphoresis, and Iveadache. Pa-tients with this process exhibit respiratory alkalosis because they are rapidly blowing off their carbon dioxide content (the acid component of arterial blood gases), not acidosis. Solitary left arm pain does not occur with hyperventilation.
Question 38.
The presence of a barrel chest and cyanosis are indicative of which of the following respiratory pathologies?
(a) Emphysema
(b) Chronic bronchitis
(c) Asthma
(d) Pulmonary fibrosis
Answer:
(a) Emphysema
Rationale:
Barrel chest is a hallmark sign of emphysema because of the abnormal permanent enlargement of the air spaces distal to the terminal bronchioles. Emphyse- mic patients end up creating increased dead space (any place where air is transported but does not participate in diffusion of gases) and decreased functional lung tissue. Barrel chest is not indicative of chronic bronchi¬tis, asthma, or pulmonary fibrosis. Cyanosis can occur in many patients in which oxygen delivery is impaired.
Question 39.
Administration of high levels of oxygen to a patient with chronic bronchitis as a subcategory of chronic obstructive pulmonary disease (COPD) can result in which of the following conditions?
(a) Increased ventilatory drive
(b) Diminished ventilatory drive
(c) Ventilation/perfusion mismatch
(d) Profound decrease in PaC02
Answer:
(b) Diminished ventilatory drive
Rationale:
If high levels of oxygen are administered, the patient with chronic bronchitis can lose the hypoxic respi¬ratory drive and respirations will decrease or even stop. Asrespirations decrease, PaC02 levels rise, not fall. A patient with chronic bronchitis has had an elevated carbon dioxide level for a prolonged time and no longer depends on carbon diox¬ide level changes to regulate ventilations. Instead, the patient depends on hypoxia or lower Pa02 level changes to regulate ventilations. This leads to a ventilation/perfusion mismatch. Increasing the oxygen level does not increase the ventilation/ perfusion mismatch. Patients with chronic obstructive pulmo¬nary disease (COPD) are further subdivided into the two cat-egories of chronic bronchitis and emphysema, each with their own specific pathophysiologic changes and manifestations.
Question 40.
Which of the following is most commonly associated with laryngotracheobronchitis (croup)?
(a) Crackles
(b) Barking cough
(c) Wheezing
(d) Friction rub
Answer:
(b) Barking cough
Rationale:
A barking cough occurs most commonly with croup; coughing frequency increases at night. Crackles, or rales, are popping noises heard most often during inspiration. They indicate that fluid, pus, or mu¬cus is in the smaller airways. A friction rub, caused by the two pleural surfaces rubbing together, is not heard with croup. Wheezing is a high-pitched musical sound. It can be heard during inspiration and expiration and usu¬ally accompanies an asthma attack or bronchospasm.
Question 41.
Which of the following is the most common cause of chest trauma-related deaths?
(a) Falls
(b) Assaults
(c) Firearms
(d) Motor vehicle crash
Answer:
(d) Motor vehicle crash
Rationale:
Motor vehicle accidents account for two- thirds of all chest trauma-related deaths. Other causes of thoracic injuries include falls, assaults, firearms, stabbings, crush injuries, and motor vehicle-pedestrian accidents.
Question 42.
The patient with chronic bronchitis requires careful monitoring when receiving which of the following treatments?
(a) Oxygen therapy
(b) Increased fluids
(c) Humidified air
(d) Postural drainage
Answer:
(a) Oxygen therapy
Rationale:
The patient with chronic bronchitis should be monitored closely when given low-flow oxygen to decrease the chances of depressing the respiratory drive because hypoxia becomes the stimulus to breathe for these patients. Increasing fluids to liquefy secretions, humidifying the air, and performing postural drainage are also important therapies for a patient with chronic bronchitis.
Question 43.
Which of the following return statements indicates successful education of a patient with acute bronchitis?
(a) “As long as I limit my fluid intake, I shouldn’t have further symptoms.”
(b) “1 can continue smoking as long as I don’t smoke in a closed area.”
(c) “1 should take my antibiotic and that will cure my problem.”
(d) “I should use my bronchodilator to reduce symptoms.”
Answer:
(d) “I should use my bronchodilator to reduce symptoms.”
Rationale:
Medications prescribed for acute bronchitis may include bronchodilators, corticosteroids, expecto-rants, and antianxiety drugs. The patient must increase fluid intake to liquefy secretions. Bronchitis is an inflam-mation resulting from irritation of the bronchial mucosa by pollen, smoking, or inhalation of irritating substances. Environmental irritants must be removed. Acute bronchi-tis is caused by a virus and therefore, antibiotics are not appropriate for this disease process.
Question 44.
Which of the following symptoms would a patient with a diagnosis of chronic bronchitis exacerbation most likely manifest?
(a) Slight dry cough
(b) Wet, productive cough
(c) Inspiratory wheezing
(d) Pursed lip breathing
Answer:
(b) Wet, productive cough
Rationale:
Patients with chronic bronchitis have an overproduction of sputum, which provides the basis for a wet and productive cough. This is also a strong setup for infectious processes as bacteria have an invit¬ing place to grow. Wheezing and pursed lip breathing' are associated with emphysema. Emphysemic patients will have no cough. If they do cough, it is a minor dry, hacking-type cough.
Question 45.
A patient presents with a history of mild respiratory infection and a dry cough for the past week. The patient has recently developed a loose, productive cough. He is afebrile, appears nontoxic, and has had no difficulty eating or drinking. What is the most likely diagnosis for this patient?
(a) Asthma attack
(b) Acute bronchitis
(c) Pneumonia
(d) Chronic bronchitis
Answer:
(b) Acute bronchitis
Rationale:
Patients with acute bronchitis initially have a dry cough that becomes more productive and they usually appear nontoxic. Most patients with an acute asthma attack have exposure to allergens as an impor-tant history finding and are usually in acute respiratory distress with wheezing. A patient with pneumonia gener-ally has an elevated temperature, productive cough, and coarse crackles. A patient with chronic bronchitis has a chronic productive cough.
Question 46.
Treatment for a patient with a rib fracture includes which of the following?
(a) Placing the patient in the supine position.
(b) Taping the chest circumferentially to relieve pain.
(c) Controlling pain to assist with breathing.
(d) Forcing fluids to prevent dehydration.
Answer:
(c) Controlling pain to assist with breathing.
Rationale:
Pain control for a patient with rib fractures is a priority to ensure adequate expansion of lung tissue and to facilitate turning, coughing, and deep breathing. The patient should be placed in high Fowler’s position to facilitate gas exchange and breathing. Avoid circumfer-ential taping of the chest or rib belts because this predis-poses the patient to atelectasis and pneumonia. The lung directly below the fractured rib is often bruised (pulmo-nary contusion). Fluids should be monitored closely to decrease the risk of acute respiratory distress syndrome (ARDS) which causes a noncardiac pulmonary edema.
Question 47.
Effective treatment of a patient with pulmonary contusion is best identified by which of the following?
(a) Diminished breath sounds
(b) Increased respiratory rate and effort
(c) Decreased complaints of pain
(d) Respiratory acidosis
Answer:
(c) Decreased complaints of pain
Rationale:
Effective treatment of a patient with pul-monary contusion is evidenced by decreased com-plaints of pain, equal bilateral breath sounds, and an improved respiratory rate, rhythm, depth, and effort. Other indicators of effective treatment include vital signs within normal limits, arterial blood gases within acceptable limits, and improved skin and mucous membrane color.
Question 48.
Which of the following interventions is most appropriate for a patient with a pulmonary contusion?
(a) Restrict intravenous fluid administration.
(b) Provide supplemental humidified oxygen.
(c) Position the patient to facilitate breathing.
(d) Assist with removal of secretions.
Answer:
(a) Restrict intravenous fluid administration.
Rationale:
If the patient is not exhibiting symptoms of hypovolemic shock, intravenous fluids should be re-stricted during initial care. While providing supplemen-tal oxygen, positioning the patient to facilitate breathing and assisting with removal of secretions are all treatments for pulmonary contusion; limiting IV fluid administration is associated with the best outcome for the patient.
Question 49.
Which of the following findings is commonly
(a) Falls
(b) Assaults
(c) Firearms
(d) Motor vehicle crash
Answer:
(b) Assaults
Rationale:
Fluid overload, as evidenced by crackles in the lower lung fields, is consistently associated with a poor outcome in patients with pulmonary contusions. A pulmonary contusion normally causes an inflammatory response that results in an increase in temperature and white blood cells. The patient with a pulmonary contusion is expected to have hemoptysis. The blood may be expectorated or suc¬tioned from the endotracheal tube if the patient is intubated.
Question 50.
Which of the following is the most appropriate position to facilitate oxygen exchange in the patient with acute respiratory distress syndrome (ARDS)?
(a) Side-lying position with the right lung down
(b) Side-lying position with the left lung down
(c) Prone position slightly on the right side
(d) Semi-Fowler’s position lying on the left side
Answer:
(c) Prone position slightly on the right side
Rationale:
Research has shown that improved oxygen-ation parameters are seen when a patient with acute needle decompression.
Question 51.
Which of the following is the most important treatment for the patient with tension prfeumothorax?
(a) Elevate the head of the patient’s bed.
(b) Administer 100% oxygen.
(c) Infuse intravenous normal saline slowly.
(d) Assist with needle decompression.
Answer:
(d) Assist with needle decompression.
Rationale:
All of the options listed are important in the treatment of tension pneumothorax, but the most important is needle decompression. A 14-G needle in-serted into the second intercostal space at the midclavicu-lar line on the affected side is appropriate. A chest tube insertion should follow sucking noise at the site of injury but will not usually be associated with loss of blood.
Question 52.
Which of the following is the definitive therapy for a patient with a massive hemothorax?
(a) Emergency thoracotomy
(b) Chest tube insertion
(c) Fluid resuscitation
(d) Supplemental oxygenation
Answer:
(a) Emergency thoracotomy
Rationale:
The definitive treatment for a patient with a massive hemothorax is emergency thoracotomy. It is im¬perative to identify and repair the source of bleeding. Tem¬porary measures to stabilize the patient include chest tube insertion and, possibly, autotransfusion, fluid resuscitation (crystalloids and colloids), and supplemental oxygenation.
Question 53.
Which of the following is a true statement regarding emphysema?
(a) Emphysema creates increased dead space in the lung fields.
(b) An emphysemic patient is the one who develops cor pulmonale.
(c) A stocky build is a normal body shape for emphysemic patients.
(d) Respiratory infections are dominant in the patient with emphysema.
Answer:
(a) Emphysema creates increased dead space in the lung fields.
Rationale:
An increase in dead space occurs with emphysema due to destruction of alveolar walls and overdistension of the alveoli. When this happens, these alveoli are no longer functional because they cannot par-ticipate in diffusion of gases. This increases dead space a space where air is transported but does not assist with the work of the pulmonary system such as with the trachea. Cor pulmonale, right-sided heart failure caused by a pulmonary issue, is associated with chronic bronchitis. Chronic bronchitis patients usually have a stocky build as opposed to the thin extremities and barrel chest of the emphysema patient, and respiratory infections are more prone in the chronic bronchitis patient due to the increase in secretions.
Question 54.
A patient is transported via EMS to the emergency department after having fallen from a roof. Upon assessment, the nurse notes lack of breath sounds on the left side. A chest tube is inserted in the left chest, but instead of releasing air, the catheter expels blood. What might be the reason for this?
(a) Tension pneumothorax
(b) Open pneumothorax
(c) Hemothorax
(d) Simple pneumothorax
Answer:
(c) Hemothorax
Rationale:
A hemothorax is caused by free blood in the pleural space, usually caused by trauma, which will result in diminished or absent breath sounds on the affected side. A tension pneumothorax or simple pneu-mothorax will not expel blood through the chest tube.
An open pneumothorax will present with a bubbling, sucking noise at the site of injury but will not usually be associated with loss of blood.
Question 55.
Which of the following is the primary goal in the treatment of a patient with acute respiratory distress syndrome (ARDS)?
(a) Treating the underlying condition
(b) Maintaining nutritional requirements
(c) Maintaining adequate tissue oxygenation
(d) Preventing secondary infection
Answer:
(a) Treating the underlying condition
Rationale:
Identifying and treating the underlying con-dition is the primary goal. If the condition causing acute respiratory distress syndrome (ARDS) is not treated, in-jury to the lung will continue, preventing adequate tissue oxygenation and predisposing the patient to a secondary infection. Later, the nurse should also provide adequate nutritional support in the form of increased protein and calories and limited carbohydrate intake.
Question 56.
Which of the following findings indicates that a chest tube is NOT effective in the management of a pneumothorax?
(a) Patient resting, pulse oximetry 96% on 2 L/nasal cannula
(b) Breath sounds equal bilaterally, equal chest excursion
(c) Patient anxious, respirations 36 breaths/minute
(d) Trachea midline, jugular veins not distended
Answer:
(c) Patient anxious, respirations 36 breaths/minute
Rationale:
After chest tube insertion, the patient should be calm. A patient who is anxious with rapid respira-tions is showing signs of respiratory distress. If the chest tube is effective, respirations and pulse oximetry reading should be within normal limits. Breath sounds should be heard in all lobes bilaterally with equal excur-sion of chest. The trachea should be midline without jugular venous distension.
Question 57.
A patient is admitted to the emergency department after being involved in a single-car collision. On inspection, the emergency nurse finds tachypnea, bulging of the intercostal spaces on the left side, labored breathing with accessory muscle use, and jugular venous distension. There is left-sided hyperresonance on percussion and absent breath sounds on auscultation on the left. What is the most likely diagnosis based on these findings?
(a) Tension pneumothorax
(b) Flail chest
(c) Ruptured diaphragm
(d) Massive hemothorax
Answer:
(a) Tension pneumothorax
Rationale:
Tension pneumothorax presents with severe respiratory distress, hypotension, diminished breath sounds over the affected area, hyperresonance, jugular venous distension and, eventually, tracheal shift to the unaffected side. A finding of multiple rib fractures
in a patient with respiratory distress verifies a diagnosis of flail chest.
A patient with a ruptured diaphragm pres-ents with hyperresonance on percussion, hypotension, dyspnea, dysphagia, shifted heart sounds, and bowel sounds in the lower to middle chest. A patient with mas-sive hemothorax shows signs of shock (tachycardia and hypotension), dullness on percussion on the injured side, decreased breath sounds on the injured side, respiratory distress, and possibly, mediastinal shift.
Question 58.
Which of the following interventions would be LEAST effective for a patient with rib fractures who is breathing deeply and coughing productively?
(a) Incentive spirometry every 2 hours
(b) Sitting in a chair at the bedside three times per day
(c) Splinting the chest when coughing
(d) Suctioning the patient every 2 hours
Answer:
(d) Suctioning the patient every 2 hours
Rationale:
If the patient is effectively coughing pro-ductively and removing secretions, suctioning can be harmful. Suctioning can cause mucosal trauma, hypox-emia, and even pulmonary infection. Incentive spirom-etry every 2 hours, sitting in a chair at the bedside three times per day, and splinting the chest wall to facilitate coughing are all measures to prevent pneumonia.
Question 59.
Which of the following is the most likely finding on a lateral neck radiograph in a child with epiglottitis?
(a) Supraglottic narrowing
(b) Steeple sign
(c) Thickened mass
(d) Subglottic narrowing
Answer:
(c) Thickened mass
Rationale:
The lateral neck radiograph of a child with epiglottitis shows a thickened mass called the Thumb-print Sign. The steeple sign is found in the patient with viral croup syndrome and is demonstrated with superior tapering in the trachea, often seen on the chest radio-graph. Subglottic narrowing with membranous tracheal exudate is found in bacterial tracheitis. Supraglottic nar-rowing is not a diagnostic indicator.
Question 60.
Measuring lung function by determining the patient’s peak expiratory flow rate (PEFR) is an important step in determining the success of asthma management. Which of the following is the optimal PEFR?
(a) PEFR greater than 80% of predicted or personal best
(b) PEFR variability of 20% to 30%
(c) PEFR less than 50% of predicted or personal best
(d) PEFR variability of less than 30%
Answer:
(a) PEFR greater than 80% of predicted or personal best
Rationale:
The optimal peak expiratory flow rate (PEFR) is greater than 80% of predicted or personal best with a variability of less than 20%. This is a simple bedside test. Monitoring PEFR helps assess the severity of obstruction. The nurse should evaluate the patient’s response to treat¬ment and detect changes in airflow. If PEFR is increasing and subjective symptoms are decreasing, medication or dosage does not need to be changed.
If PEFR is decreasing and symptoms are increasing, the patient can better judge his status and adjust medications appropriately.
Question 61.
Air trapping, inflammation of smooth muscles, and mucus secretion are classic signs of which of the following respiratory illnesses?
(a) Pulmonary effusion
(b) Asthma attack
(c) Chronic bronchitis
(d) Acute respiratory distress syndrome
Answer:
(b) Asthma attack
Rationale:
Inflammation of smooth muscle leading to constriction of bronchioles and mucus production results in air trapping, respiratory acidosis, and hypoxemia, and are the classic symptoms of asthma. Pulmonary effusion is caused by excessive fluid accumulation in the pleural space. Chronic bronchitis is a narrowing of the airway pas¬sages and an increase in mucus production, but it does not produce air trapping. Acute respiratory distress syndrome (ARDS) is an acute physiologic syndrome characterized by noncardiac pulmonary edema caused by increased pul¬monary capillary permeability, high PEEP, and low oxygen saturation despite the use of supplemental oxygen.
Question 62.
Right-sided heart failure can occur secondary to a pulmonary embolus (PE). Which of the following findings is consistent with this development?
(a) Physiologic S2 split heart sound
(b) Peaked P wave on electrocardiogram (ECG)
(c) Presence of expiratory wheeze
(d) Pericardial friction rub
Answer:
(b) Peaked P wave on electrocardiogram (ECG)
Rationale:
Elevated pulmonary pressures resulting from pulmonary emboli can lead to dysfunction of the right heart, which, in turn, can lead to an increase in right atrial volume, showing an altered P wave on the ECG. In
lead II, the P wave is taller and more peaked than a normal P wave. A physiologic S2 split is normal. When pulmonary pressures become severely elevated, the split becomes pathologic. Breath sounds are generally clear in a patient with pulmonary emboli. A pleural friction rub maybe heard but is not due to the right-sided heart failure.
Question 63.
Which of the following diagnostic studies most accurately identifies the presence of a pulmonary embolus (PE)? (a) Bronchoscopy
(b) Chest radiograph
(c) Ventilation/perfusion (V/Q) scan
(d) Pulmonary angiography
Answer:
(d) Pulmonary angiography
Rationale:
Although riskier than a V/Q scan, pulmonary angiography confirms the presence of a pulmonary embolus. Bronchoscopy is typically used in differential di¬agnosis of pneumonia. A chest radiograph is usually done to rule out other pulmonary problems, such as pneumonia and atelectasis. A V/Q scan is used to locate the inad¬equately perfused area; however, results are not definitive. The most frequent diagnostic test used now is a computed tomography (CT) for pulmonary embolus.
Question 64.
Diagnostic tests that might be helpful in supporting a diagnosis of pneumonia would include which of the following?
(a) Complete blood count (CBC) and chest radiograph
(b) Complete blood count (CBC) and lumbar puncture
(c) Chest radiograph and serum sedimentation rate
(d) Serum creatinine and electrolytes
Answer:
(a) Complete blood count (CBC) and chest radiograph
Rationale:
A complete blood count (CBC) is helpful in determining the presence of infection and identify¬ing the microbial (viral, bacterial, or fungal) agent. A chest radiograph can identify the location of the pneu-monia. Sedimentation rate, electrolytes, serum creatinine and lumbar puncture do not assist in the differential diag¬nosis of pneumonia.
Question 65.
Which of the following is the most common cause of traumatic pneumothorax?
(a) Fractured ribs
(b) Gunshot wound
(c) Barotrauma
(d) Central line insertion
Answer:
(a) Fractured ribs
Rationale:
The most common cause of traumatic pneu-mothorax is fractured ribs. Other common causes include penetrating trauma (gunshot or knife wound), insertion of a central venous pressure catheter or central line, barotrauma in mechanically ventilated patients, and closed pleural biopsy.
Question 66.
A patient with chronic obstructive pulmonary disease (COPD) is given discharge instructions regarding nutritional support. Which of the following statements indicates the need for further teaching?
(a) “I should eat five or six small meals each day.”
(b) “I will limit my fluid intake at mealtime.”
(c) “I should eat mostly carbohydrate foods.”
(d) “I should rest for 30 minutes before each meal.”
Answer:
(c) “I should eat mostly carbohydrate foods.”
Rationale:
The patient with chronic obstructive pulmo-nary disease (COPD) has a markedly increased need for protein, not carbohydrates, and calories to main-tain an adequate nutritional status. The patient’s diet should be high in both protein and calories and should be divided into five or six small meals per day. Fluid intake should be maintained at 3 L/day unless contrain¬dicated. Fluids should be taken between meals to reduce gastric distension and pressure on the diaphragm. The patient with COPD should rest for 30 minutes before each meal to conserve energy and decrease dyspnea.
Question 67.
Impaired pulmonary capillary permeability, high positive end-expiratory pressure (PEEP) on a ventilator, and an inability to maintain adequate oxygen saturation are signs of which of the following?
(a) Emphysema
(b) Pulmonary effusion
(c) Chronic bronchitis
(d) Acute respiratory distress syndrome
Answer:
(d) Acute respiratory distress syndrome
Rationale:
Acute respiratory distress syndrome (ARDS) is an acute physiologic syndrome charac-terized by noncardiac pulmonary edema caused by increased pulmonary capillary permeability, high PEEP, and low oxygen saturation despite the use of supplemental oxygen. Emphysema is a permanent con-dition that is caused by alveolar destruction. Pulmonary effusion is caused by excessive fluid accumulation in the pleura, and chronic bronchitis is a narrowing of the airway passages and an increase in mucus production.
Question 68.
Which of the following is the most appropriate intervention for a patient with chronic obstructive pulmonary disease (COPD)?
(a) Administer 100% oxygen via non-rebreather mask.
(b) Obtain and monitor arterial blood gas (ABG) levels.
(c) Restrict fluids to only at meal times.
(d) Place the patient in a supine position.
Answer:
(b) Obtain and monitor arterial blood gas (ABG) levels.
Rationale:
Monitoring arterial blood gas (ABG) levels is the appropriate intervention for the chronic obstructive pulmonary disease (COPD) patient. The patient with COPD has abnormal ABG levels, which may predispose him to respiratory distress. The patient is hypoxemic with ; hypercapnia. Oxygen should be administered at low con¬centrations to maintain hypoxic drive. If the fa02 remains inadequate at low doses, the nurse should increase the oxygen while continuously monitoring the patient’s respi¬ratory status. A patient with COPD usually benefits from adequate hydration to liquefy secretions. Allow the patient to assume a position that facilitates ventilation, usually a forward-leaning high Fowler’s position.
Question 69.
Which of the following is the most likely laboratory finding in a patient with early acute respiratory distress syndrome (ARDS)?
(a) Elevated CO level
(b) Decreased Pa02
(c) Elevated PaC02
(d) Decreased HC03“
Answer:
(b) Decreased Pa02
Rationale:
Hypoxemia is a universal finding in acute respiratory distress syndrome (ARDS). The PaC02 is low early in the disease because of hyperventilation, and rises later in the disease because of fatigue and worsening clinical status. The bicarbonate level may be low in ARDS and is related to reduced tissue oxygenation. Reduced oxy¬genation leads to anaerobic metabolism and accumulating lactate. HC03 “ in the serum combines with the lactate, re¬ducing circulating HCO," levels. The carboxyhemoglobin level is increased in a patient with an inhalation injury, which commonly progresses to ARDS.
Question 70.
Which of the following is the definition of flail chest?
(a) An unstable segment of the intercostal muscles.
(b) A compressed rib cage with open chest wound
(c) A fracture of two adjacent ribs, bilaterally
(d) A fracture of two or more ribs in two or more places
Answer:
(d) A fracture of two or more ribs in two or more places
Rationale:
Flail chest is a fracture of two to three or more ribs (dependent on the reference used] in two or more places, resulting in a free-floating segment of the chest wall. This instability causes paradoxical chest movement, which is commonly a sign of flail chest; however, until the chest muscles relax or pain relief is achieved, paradoxical movements are unlikely to be seen. The instability is in the rib cage itself not the intercostals. Flail chest is usually a closed injury. Bilateral injury is not required in flail chest. If bilateral injury is present, the risk of mortality increases drastically.
Question 71.
A 10-year-old with a history of asthma is diagnosed with status asthmaticus. The emergency nurse knows this patient:
(a) Has severe expiratory wheezing.
(b) Has not responded to treatment.
(c) Has been taking antibiotics.
(d) Has underlying pneumonia.
Answer:
(b) Has not responded to treatment.
Rationale:
Status asthmaticus is asthma with moder¬ate to severe airway obstruction that does not respond to initial treatment. The child’s wheezing stops when status asthmaticus develops because the airways are ob-structed. Antibiotics are not treatment for asthma and the child has no signs of pneumonia.
Question 72.
A-15-month-old has been diagnosed with croup. Which of the following is most concerning?
(a) Inspiratory stridor is heard
(b) Mother cannot calm the child
(c) Child has a barking cough
(d) Child is restless when sleeping
Answer:
(b) Mother cannot calm the child
Rationale:
Inconsolability is cause for alarm in an in-fant. In a child with respiratory problems, the inability of caregivers to soothe may be an indication of increasing hypoxia. Typical symptoms of croup include inspiratory stridor and a barking cough. Children are often restless when sleeping when they are ill.
Question 73.
A 4-year-old is brought to the emergency department by his mother who reports he swallowed a small toy. Which finding by the emergency nurse indicates complete airway obstruction?
(a) Gagging
(b) Coughing
(c) Aphasia
(d) Tachypnea
Answer:
(c) Aphasia
Rationale:
With complete airway obstruction, the child cannot cough, speak, or breathe. Tachypnea, gagging, and coughing are signs of an incomplete obstruction. Other signs include vomiting, wheezing, cyanosis, and increased work of breathing.
Question 74.
A child with cystic fibrosis (CF) has a cough and runny nose and has been diagnosed with an upper respiratory infection. Which action by the mother indicates appropriate learning?
(a) Ensuring the patient eats a complete diet every day
(b) Checking the child’s temperature twice daily
(c) Offering the child orange juice throughout'the day
(d) Increasing chest physiotherapy to four times per day
Answer:
(d) Increasing chest physiotherapy to four times per day
Rationale:
Increasing chest physiotherapy to fourtimes a day is the appropriate intervention. For a child with cystic fibrosis (CF), a simple upper respiratory infection may develop into pneumonia if the thick secretions are not loosened and removed by percussion and postural drainage. Making sure the child has an ad-equate diet, taking the child’s temperature, and giving the child orange juice are important but not as vital as increasing the physiotherapy.
Question 75.
An infant with a history of a respiratory tract infection is brought to the emergency department and is diagnosed with bronchiolitis and respiratory syncytial virus (RSV). The emergency nurse institutes which of the following types of precautions?
(a) Droplet
(b) Standard
(c) Contact
(d) Airborne
Answer:
(c) Contact
Rationale:
The child with respiratory syncitial virus (RSV) should be placed on contact precautions. RSV is highly communicable and can live on surfaces for up to 6 hours. Standard precautions will not be enough to prevent spreading this organism. Gown and gloves should be worn when entering the room. Droplet and airborne precautions are not necessary.