Respiratory Disorders NCLEX Review Answers and Rationale

by: Daisy Jane, RN

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1.    Answer: C. Mantoux test is read 48-72 hours after injection.
2.    Answer: A. Mantoux tests are done intradermally.
3.    Answer: D. Mantoux test is considered positive for Mycobacterium Tubercle Bacilli if the induration is 10 mm or more. For HIV positive clients, induration of 5mm is considered positive. 
4.    Answer: C. The client is instructed to remove metals from the chest. Consent, NPO post midnight and atropine sulfate administration are not needed for this procedure.
5.    Answer: A. 

Nursing interventions before bronchogram:
•    Secure written consent
•    Check for allergies (seafoods and iodine or anesthesia)
•    NPO 6-8 hours
•    Pre-op meds: atropine sulfate and valium, topical anesthesia sprayed followed by local anesthetic into the larynx
•    Have oxygen and antispasmodic agents ready

Nursing Interventions after bronchogram
•    Side-lying position
•    NPO until cough and gag reflex returns
•    Cough and deep breathe clients
•    Low grade fever common
6.    Answer: D. After thoracentesis the client is placed or turned to the unaffected side to prevent leakage of fluid in the thoracic cavity.
7.    Answer: D. The client should be hyperventilated with 100% oxygen before and after suctioning.
8.    Answer: A. Position a conscious person who has a functional gag reflex in the semi fowler’s position with the head turned to one side for oral suctioning or with the neck hyper extended for nasal suctioning. If the client is unconscious place the patient a lateral position facing you.
9.    Answer: A. Suction bottle will have continuous suctioning while the water seal bottle will have an intermittent suctioning.
10.    Answer: D. A water seal bottle is expected to be observed for intermittent bubbling. Therefore, the nurse should only make sure that bottle is at least 2-3 feet below the chest. Checking for an air leak would be the nurse’s action if the water seal has continuous bubbling. Kinks should be check for possible obstruction if no bubbling is noted in the water seal bottle.
11.    Answer: C. In removal of the chest tube the nurse should prepare the following:
•    Petrolatum gauze
•    Suture removal kit
•    Sterile gauze
•    Adhesive tape
12.    Answer: A. As the chest tube is removed the client should be instructed to exhale deeply and do valsalva maneuver. The client is placed in a semi-fowler’s position before the chest tube is removed.
13.    Answer: B. Because the pain is felt above the eyebrows the affected sinus is the frontal sinus.
Pain assessment in sinusitis
•    Maxillary: cheek and upper teeth
•    Frontal: above eyebrows
•    Ethmoid: in and around the eyes
•    Sphenoid: behind eye, occiput, top of the head
14.    Answer: C. ASA is avoided in sinusitis as it increases the risk of developing nasal polyps.
15.    Answer: B.
Management for sinusitis:
•    Rest
•    Increase fluids
•    Hot wet packs
•    Codeine
•    Amoxicillin and other anti-infectives
•    Nasal decongestants
•    Irrigation of maxillary sinuses with warm NSS
16.    Answer: A.  After a Caldwell-Luc Operation (Radical Antrum Surgery) the following should be instructed to the client:
•    Do not chew on the affected side
•    Caution with oral hygiene to prevent trauma of incision
•    Do not wear dentures for 10 days
•    Do not blow nose for 2 weeks after the removal of the packing
•    Avoid sneezing for two weeks after surgery
17.    Answer: D. Surgery is indicated for patients with tonsillitis recurring 5-6 times a year.
18.    Answer: B. The should assess for Upper respiratory tract infection (URTI). Coughing and sneezing postoperatively due to URTI may cause bleeding.
19.    Answer: C. to promote comfort the nurse must administer acetaminophen to alleviate pain from the operation. Also, ice collar can be applied to decrease pain thus, promoting comforting. Assisting the client to the proper position after tonsillectomy (semi-fowler’s) while supporting the position with pillows is also one way to promote comfort. The only choice that does not promote comfort but monitors for hemorrhage is the assessment for frequent swallowing, thus, it is the correct answer (C).
20.    Answer: B. after tonsillectomy, the client’s stool will be black or dark for a few days due to the swallowed blood.
21.    Answer: D. Allergy (extrinsic) and inflammation (intrinsic) triggers the release of chemical mediators that causes narrowing of the airways and spasm. These mediators are:
•    Serotonin
•    Prostaglandin
•    Bradykinin
•    Histamine
•    Leukotrienes
22.    Answer: B. An overdistended and non-functional alveoli is a condition called emphysema. Atelectasis is the collapse of a part or the whole lung. Empyema is the presence of pus in the lung.
23.    Answer: A. The strategy used in this item is the “umbrella effect.” Hemothorax (blood), hydrothorax (water) and pyothirax (pus; also called empyema) are all types of pleural effusion. The three choices are under pleural effusion (umbrella effect), thus the correct answer is A.
24.    Answer: B. Diet for COPD: High calorie, high protein and low carbohydrate diet
•    High caloric diet provides source of energy.
•    High protein diet helps maintain integrity of alveolar walls.
•    Low carbohydrate diet limits carbon dioxide production (natural end product). The client with COPD has difficulty exhaling carbon dioxide.
25.    Answer: D. Benadryl (Dipenhydramine) is an antihistamine not bronchodilator.

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