Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
Which age-related changes in the respiratory system cause decreased secretion clearance? (Select all that apply.)
A. Decreased functional cilia
Decreased functional cilia. With aging, the number and activity of cilia decline, reducing mucociliary clearance. This makes it harder for mucus and debris to move upward and out of the airways, predisposing older adults to respiratory infections.
B. Decreased force of cough
Decreased force of cough. Age-related weakening of respiratory muscles and reduced chest wall elasticity decrease cough strength, limiting the ability to clear secretions effectively. This contributes to mucus retention and airway compromise.
C. Decreased chest wall compliance
Decreased chest wall compliance. Although reduced compliance affects breathing mechanics and expansion, it does not directly influence the body’s ability to clear secretions.
D. Small airway closure earlier in expiration
Small airway closure earlier in expiration. This contributes to air trapping and reduced ventilation efficiency, but it does not directly cause decreased secretion clearance.
E. Decreased functional immunoglobulin A (IgA)
Decreased functional immunoglobulin A (IgA). IgA helps defend against pathogens on mucosal surfaces. A decline in IgA levels and effectiveness weakens immune protection, allowing microorganisms to proliferate in retained secretions.
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Full Explanation
Age-related changes that lead to decreased secretion clearance include decreased functional cilia, decreased force of cough, and decreased functional immunoglobulin A (IgA). These physiological changes impair the respiratory system’s ability to remove mucus and trapped pathogens, increasing the risk of airway obstruction and infection in older adults.
Rationale for correct answers:
1. Decreased functional cilia. With aging, the number and activity of cilia decline, reducing mucociliary clearance. This makes it harder for mucus and debris to move upward and out of the airways, predisposing older adults to respiratory infections.
2. Decreased force of cough. Age-related weakening of respiratory muscles and reduced chest wall elasticity decrease cough strength, limiting the ability to clear secretions effectively. This contributes to mucus retention and airway compromise.
5. Decreased functional immunoglobulin A (IgA). IgA helps defend against pathogens on mucosal surfaces. A decline in IgA levels and effectiveness weakens immune protection, allowing microorganisms to proliferate in retained secretions.
Rationale for incorrect answers:
3. Decreased chest wall compliance. Although reduced compliance affects breathing mechanics and expansion, it does not directly influence the body’s ability to clear secretions.
4. Small airway closure earlier in expiration. This contributes to air trapping and reduced ventilation efficiency, but it does not directly cause decreased secretion clearance.
Take-home points:
- Aging decreases cilia activity, cough strength, and IgA function, impairing secretion clearance.
- Impaired clearance increases the risk of infection, mucus retention, and atelectasis.
- Encourage hydration, pulmonary hygiene, deep breathing, and coughing exercises to promote secretion removal.
- Preventive care such as vaccinations and respiratory monitoring helps reduce complications in older adults.
Similar Questions
Palpation is the assessment technique used to find which abnormal findings? (Select all that apply.)
A. Stridor
Stridor. Stridor is a high-pitched inspiratory sound heard primarily with auscultation, not palpation.
B. Finger clubbing
Finger clubbing. Palpation of the nail beds can confirm the presence of clubbing, which indicates chronic hypoxemia associated with conditions such as lung cancer, bronchiectasis, or chronic obstructive pulmonary disease (COPD).
C. Tracheal deviation
Tracheal deviation. By gently palpating the trachea at the suprasternal notch, the nurse can detect deviation from the midline, which may occur with pneumothorax, pleural effusion, or atelectasis.
D. Limited chest expansion
Limited chest expansion. Placing hands on the posterior chest wall allows the nurse to assess for symmetry and depth of chest movement during respiration. Decreased or asymmetric expansion may indicate lung collapse, pleural effusion, or pneumonia.
E. Increased tactile fremitus
Increased tactile fremitus. Palpation while the patient repeats a phrase (e.g., “ninety-nine”) can detect vibration transmission through the chest wall. Increased fremitus suggests lung consolidation, as in pneumonia, where sound waves travel more efficiently through dense tissue.
F. Use of accessory muscles
Use of accessory muscles. The use of neck and shoulder muscles during breathing is observed visually, not palpated.
Full Explanation
Palpation is used to assess finger clubbing, tracheal deviation, limited chest expansion, and increased tactile fremitus. These findings provide important information about underlying respiratory or cardiac abnormalities and help identify structural or functional changes in the lungs and thorax.
Rationale for correct answers:
2. Finger clubbing. Palpation of the nail beds can confirm the presence of clubbing, which indicates chronic hypoxemia associated with conditions such as lung cancer, bronchiectasis, or chronic obstructive pulmonary disease (COPD).
3. Tracheal deviation. By gently palpating the trachea at the suprasternal notch, the nurse can detect deviation from the midline, which may occur with pneumothorax, pleural effusion, or atelectasis.
4. Limited chest expansion. Placing hands on the posterior chest wall allows the nurse to assess for symmetry and depth of chest movement during respiration. Decreased or asymmetric expansion may indicate lung collapse, pleural effusion, or pneumonia.
5. Increased tactile fremitus. Palpation while the patient repeats a phrase (e.g., “ninety-nine”) can detect vibration transmission through the chest wall. Increased fremitus suggests lung consolidation, as in pneumonia, where sound waves travel more efficiently through dense tissue.
Rationale for incorrect answers:
1. Stridor. Stridor is a high-pitched inspiratory sound heard primarily with auscultation, not palpation.
6. Use of accessory muscles. The use of neck and shoulder muscles during breathing is observed visually, not palpated.
Take-home points:
- Palpation assesses structural alignment, symmetry, movement, and tactile vibrations of the chest.
- Key abnormal findings include tracheal shift, limited expansion, fremitus changes, and clubbing.
- Auscultation and inspection are used for detecting breath sounds and muscle use, not palpation.
- Combined use of inspection, palpation, percussion, and auscultation ensures a complete respiratory assessment.
A nurse has been exposed to tuberculosis (TB) during care of a patient with TB and has a TB skin test performed. When is the nurse considered infected?
A. There is no redness or induration at the injection site.
There is no redness or induration at the injection site.A lack of induration means the test is negative, indicating no infection or no immune response.
B. There is an induration of only 5 mm at the injection site.
There is an induration of only 5 mm at the injection site.An induration of 5 mm is considered positive only in high-risk groups (e.g., HIV-positive individuals, recent TB contacts, or immunosuppressed patients). For healthy nurses, 10 mm is the diagnostic threshold.
C. A negative skin test is followed by a negative chest x-ray.
A negative skin test is followed by a negative chest x-ray.A negative result on both tests suggests no infection, but does not meet the criteria for being “infected.”
D. Testing causes a 10-mm red, indurated area at the injection site.
Testing causes a 10-mm red, indurated area at the injection site.An induration (raised, firm area—not redness) of 10 mm or more is considered positive in individuals such as health care workers, recent immigrants, or those with frequent exposure to TB. This indicates infection with Mycobacterium tuberculosis and the need for further evaluation, including a chest x-ray and possible interferon-gamma release assay (IGRA).
Full Explanation
A nurse is considered infected with tuberculosis (TB) when the tuberculin skin test (TST) reveals an induration of 10 mm or greater at the injection site, indicating prior exposure to Mycobacterium tuberculosis. The reaction reflects an immune response to TB antigens injected under the skin, signifying latent or active infection. Because health care workers are at increased occupational risk, this threshold is used to determine infection and guide further evaluation, including a chest x-ray and confirmatory testing.
Rationale for correct answer:
4. Testing causes a 10-mm red, indurated area at the injection site.
An induration (raised, firm area—not redness) of 10 mm or more is considered positive in individuals such as health care workers, recent immigrants, or those with frequent exposure to TB. This indicates infection with Mycobacterium tuberculosis and the need for further evaluation, including a chest x-ray and possible interferon-gamma release assay (IGRA).
Rationale for incorrect answers:
1. There is no redness or induration at the injection site.
A lack of induration means the test is negative, indicating no infection or no immune response.
2. There is an induration of only 5 mm at the injection site.
An induration of 5 mm is considered positive only in high-risk groups (e.g., HIV-positive individuals, recent TB contacts, or immunosuppressed patients). For healthy nurses, 10 mm is the diagnostic threshold.
3. A negative skin test is followed by a negative chest x-ray.
A negative result on both tests suggests no infection, but does not meet the criteria for being “infected.”
Take-home points:
- Induration, not redness, determines TST results.
- ≥10 mm is considered positive for health care workers.
- A positive TST requires follow-up with a chest x-ray and possible TB blood test.
- Annual TB screening helps protect healthcare personnel and patients.
What is a primary nursing responsibility after obtaining a blood specimen for ABGs?
A. Adding heparin to the blood specimen
Adding heparin to the blood specimen.Heparin is already present in the syringe before sampling to prevent clotting; adding more after collection is unnecessary and could dilute the specimen.
B. Applying pressure to the puncture site for 2 full minutes
Applying pressure to the puncture site for 2 full minutes.Pressure should be applied for at least 5 minutes (or longer if the patient is on anticoagulants) to prevent bleeding or hematoma formation.
C. Taking the specimen immediately to the laboratory in an iced container
Taking the specimen immediately to the laboratory in an iced container.ABG samples must be transported on ice to slow down cellular metabolism and preserve the accuracy of gas measurements. Delays or warm temperatures can falsely lower PaO₂ and raise PaCO₂ due to ongoing cellular activity. Prompt delivery ensures valid results for accurate assessment of the patient’s respiratory and metabolic status.
D. Avoiding any changes in oxygen intervention for 20 minutes following the procedure
Avoiding any changes in oxygen intervention for 20 minutes following the procedure.Oxygen interventions should not be altered before the ABG draw, but this restriction does not apply after the sample has been collected.
Full Explanation
The primary nursing responsibility after obtaining a blood specimen for arterial blood gases (ABGs) is to take the specimen immediately to the laboratory in an iced container. This prevents ongoing metabolism by red blood cells, which can alter gas values and lead to inaccurate results for pH, PaCO₂, and PaO₂ levels.
Rationale for correct answer:
3. Taking the specimen immediately to the laboratory in an iced container.
ABG samples must be transported on ice to slow down cellular metabolism and preserve the accuracy of gas measurements. Delays or warm temperatures can falsely lower PaO₂ and raise PaCO₂ due to ongoing cellular activity. Prompt delivery ensures valid results for accurate assessment of the patient’s respiratory and metabolic status.
Rationale for incorrect answers:
1. Adding heparin to the blood specimen.
Heparin is already present in the syringe before sampling to prevent clotting; adding more after collection is unnecessary and could dilute the specimen.
2. Applying pressure to the puncture site for 2 full minutes.
Pressure should be applied for at least 5 minutes (or longer if the patient is on anticoagulants) to prevent bleeding or hematoma formation.
4. Avoiding any changes in oxygen intervention for 20 minutes following the procedure.
Oxygen interventions should not be altered before the ABG draw, but this restriction does not apply after the sample has been collected.
Take-home points:
- ABG samples must be iced and promptly delivered to maintain accuracy.
- Heparinized syringes prevent clotting during collection.
- Firm pressure for 5 minutes reduces bleeding risk at the puncture site.
- Accurate ABG results are critical for evaluating oxygenation, ventilation, and acid–base balance.