The nurse clarifies that the cough mechanism is stimulated when:

more than 250 mL of air moves in and out of the lungs with each breath

foreign substances are propelled by the cilia toward the respiratory tract

dehumidified air enters the upper airway passages

the blood transports carbon dioxide to the lungs

Answer and Explanation

The Correct Answer is B

A. More than 250 mL of air moves in and out of the lungs with each breath: This describes tidal volume but does not directly stimulate the cough mechanism.
B. Foreign substances are propelled by the cilia toward the respiratory tract: Irritation by foreign particles stimulates the cough reflex to clear the airways.
C. Dehumidified air enters the upper airway passages: Dry air can cause airway irritation but does not consistently trigger a cough reflex.
D. The blood transports carbon dioxide to the lungs: This describes gas exchange, which does not directly relate to triggering the cough mechanism.

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Correct Answer is B

Explanation

A) Trendelenburg. This position involves tilting the patient with the head lower than the body and can worsen respiratory distress.
B) Tripod. The tripod position maximizes lung expansion by allowing the diaphragm to move freely, improving oxygenation.
C) Supine. The supine position can impair lung expansion and worsen respiratory distress.
D) Low-Fowler's Position. This position may provide minimal respiratory relief but is not as effective as the tripod position.

A. clamp the chest tube and place the patient in high Fowler's position B. immediately turn the patient to the side of the insertion site C. document findings D. check for air leaks in drainage system

Correct Answer is D

Explanation

A. Clamp the chest tube and place the patient in high Fowler’s position: Clamping the tube may cause tension pneumothorax and should be done only with a specific prescription.
B. Immediately turn the patient to the side of the insertion site: This action does not address the source of constant bubbling.
C. Document findings: Bubbling in the suction chamber can be normal, but documenting without further assessment may overlook potential system issues.
D. Check for air leaks in the drainage system: Constant bubbling may indicate an air leak, which requires immediate assessment and correction.

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The nurse clarifies that the cough mechanism is stimulated when:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is experiencing respiratory distress. Which of the following positions should the nurse assist the client into?

Correct Answer is B

Explanation

A nurse caring for a patient with a water seal type chest drainage that is on low suction assesses that there is constant bubbling in the suction container. The nurse should:

Correct Answer is D

Explanation

The nurse would determine that this patient is aware of how to use the incentive spirometer device properly when the patient:

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