51. A nurse is caring for a client immediately after removal of the endotracheal tube. The nurse reports which of the following signs immediately if experienced by the client?
a) stridor
b) occasional pink-tinged sputum
c) a few basilar lung crackles on the right
d) respiratory rate of 24 bpm
52. A nurse is assessing the functioning of a chest tube drainage system in a client who has just returned from the recovery room following a thoracotomy with wedge resection. Select all expected assessment findings
a) excessive bubbling in the water seal chamber
b) vigorous bubbling in the suction control chamber
c) 50 ml of drainage in the drainage collection chamber
d) drainage system maintained below the client's chest
e) occlusive dressing in place over the chest tube insertion site
f) fluctuation of water in the tube in the water seal chamber during inhalation and exhalation
53. A clinic nurse reads the results of a Mantoux test on a 3-year old child. The results indicate an area of induration measuring 10 mm. The nurse interpret this results as:
a) positive
b) negative
c) inconclusive
d) definitive and requiring a repeat test
54. A nurse provides home care instructions to the parents of a child hospitalized with pertussis. The child is in convalescent stage and is being prepared for discharge. Which statement by a parent indicates a need for further instructions?
a) we need to encourage our child to drink fluids
b) coughing spells may be triggered by dust or smoke
c) vomiting may occur when our child has coughing episodes
d) we need to maintain droplet precautions and a quiet environment for at least 2 weeks
55. A nurse caring for a client with a pneumothorax and who has had a chest tube inserted notes continuous gentle bubbling in the suction control chamber. What action is appropriate?
a) do nothing, because this is an expected finding
b) immediately clamp the chest tube and notify the physician
c) check for an air leak because the bubbling should be intermittent
d) increase the suction pressure so that the bubbling becomes vigorous
NCLEX Review Respiratory Questions:
ANSWERS AND RATIONALE
51) A
- the nurse reports stridor to the physician immediately. This is a high-pitched. coarse sound that is heard with the stethoscope over the trachea. Stridor indicates airway edema and places the client at risk for airway obstruction. Option B, C, and D are not signs that require immediate notification of the physician.
52) C, D, E
- the bubbling of water in the water seal chamber indicates air drainage from the client and usually is seen when intrathoracic pressure is higher than atmospheric pressure, and may occur during exhalation, coughing or sneezing. Excessive bubbling in the water seal chamber may indicate an air leak, an unexpected finding. Fluctuation of water in the water seal chamber during inhalation and exhalation is expected. An absence of fluctuation may indicate that the chest tube is obstructed or that the lung has reexpanded and that no more air leaking into the pleural space. Gentle (not vigorous) bubbling should be noted in the suction control chamber. A total of 50 ml drainage is not excessive in a client returning to the nursing unit from the recovery room. Drainage that is more than 100 ml/hr is considered excessive and requires physician notification. The chest tube insertion site is covered with an occlusive (airtight) dressing to prevent air from entering the pleural space. Positioning the drainage system below the client's chest allows gravity to drain the pleural space.
53) A
- Induration measuring 10 mm or more is considered to be a positive result in children younger than 4 years of age and in those with chronic illness or at high risk for environmental exposure to tuberculosis. A reaction of 5 mm or more is considered to be a positive result for the highest risk groups, such as the child with an immunosuppressive condition or the child with human immunodeficiency virus infection. A reaction of 15 mm or more is positive in children 4 years of age or older without any risk factors.
54) D
- Pertussis is transmitted by direct contact or respiratory droplets from coughing. The communicable period occurs primarily during the catarrhal stage. Respiratory precautions are not required during the convalescent phase. Options A, B, and C are components of home care instructions.
55) A
- Continuous gentle bubbling should be noted in the suction control chamber. Option B is incorrect. Chest tubes should only be clamped to check for an air leak or when changing drainage devices (according to agency policy). Option C is incorrect. Bubbling should be continuous and not intermittent. Option D is incorrect because bubbling should be gentle. Increasing the suction pressure only increases the rate of evaporation of water in the drainage system.
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