Question 1

The nurse palpates the posterior chest while the patient says &#34;99&#34; and notes that no vibration is felt. How should this be charted?&#10;A) Diminished expansion&#10;B) Dullness to percussion&#10;C) Absent tactile fremitus&#10;D) Decreased breath sounds

Accepted Answer

To assess for tactile fremitus, the nurse should use the palms of the hands to assess for vibration when the patient repeats a word or phrase such as "99." Different techniques are used to assess for dullness to percussion, decreased breath sounds, and diminished expansion.

Question 2

While caring for a patient with respiratory disease, the nurse observes that the patient's SpO₂ drops from 92% to 88% while the patient is ambulating in the hallway. Which action should the nurse take next?

A) Notify the health care provider.
B) Document the response to exercise.
C) Administer the PRN supplemental O₂.
D) Encourage the patient to pace activity.

Accepted Answer

The drop in SpO₂ to 85% indicates that the patient is hypoxemic and needs supplemental oxygen when exercising. The other actions also are appropriate, but the first action should be to correct the hypoxemia.

Question 3

A patient with acute shortness of breath is admitted to the hospital. Which action should the nurse take during the initial assessment of the patient?&#10;A) Complete a full physical examination to determine the systemic effect of the respiratory distress.&#10;B) Obtain a comprehensive health history to determine the extent of any prior respiratory problems.&#10;C) Delay the physical assessment and ask family members about any history of respiratory problems.&#10;D) Perform a respiratory system assessment and ask specific questions about this episode of respiratory distress.

Accepted Answer

When a patient has severe respiratory distress, only information pertinent to the current episode is obtained, and a more thorough assessment is deferred until later. Obtaining a comprehensive health history or full physical examination is unnecessary until the acute distress has resolved. A focused physical assessment should be done rapidly to help determine the cause of the distress and suggest treatment. Although family members may know about the patient's history of medical problems, the patient is the best informant for these data.

Question 4

The nurse has just received arterial blood gas (ABG) results on four patients. Which result is most important to report rapidly to the health care provider? A) pH 7.34, PaO₂ 82 mm Hg, PaCO₂ 40 mm Hg, and O₂ sat 97% B) pH 7.35, PaO₂ 85 mm Hg, PaCO₂ 45 mm Hg, and O₂sat 95% C) pH 7.46, PaO₂ 90 mm Hg, PaCO₂ 32 mm Hg, and O₂ sat 98% D) pH 7.31, PaO₂ 91 mm Hg, PaCO₂ 50 mm Hg, and O₂ sat 96%

Accepted Answer

These ABGs indicate uncompensated respiratory acidosis and should be reported to the health care provider. The other values are normal or close to normal.

Question 5

When assessing the respiratory system of a 78-year-old patient, which finding indicates that the nurse should take immediate action?&#10;A) The chest appears barrel shaped.&#10;B) The patient has a weak cough effort.&#10;C) Crackles are heard from the lung bases to the midline.&#10;D) Hyperresonance is present across both sides of the chest.

Accepted Answer

Crackles in the lower half of the lungs indicate that the patient may have an acute problem such as heart failure. The nurse should immediately accomplish further assessments, such as oxygen saturation, and notify the health care provider. A barrel-shaped chest, hyperresonance to percussion, and a weak cough effort are associated with aging. Further evaluation may be needed, but immediate action is not indicated.

Question 6

When auscultating a patient's chest while the patient takes a deep breath, the nurse hears loud, high-pitched, &#34;blowing&#34; sounds at both lung bases. The nurse will document these as&#10;A) normal sounds.&#10;B) vesicular sounds.&#10;C) abnormal sounds.&#10;D) adventitious sounds.

Accepted Answer

The description indicates that the nurse hears bronchial breath sounds that are abnormal when heard at the lung base. Adventitious sounds are extra breath sounds such as crackles, wheezes, rhonchi, and friction rubs. Vesicular sounds are low-pitched, soft sounds heard over all lung areas except the major bronchi.

Question 7

A patient is admitted to the emergency department complaining of sudden onset shortness of breath and is diagnosed with a possible pulmonary embolus. To confirm the diagnosis, the nurse will anticipate preparing the patient for a

A) positron emission tomography (PET) scan.
B) chest x-ray.
C) bronchoscopy.
D) spiral computed tomography (CT) scan.

Accepted Answer

Spiral CT scans are the most commonly used test to diagnose pulmonary emboli. A chest x-ray may be ordered but will not be diagnostic for a pulmonary embolus. Bronchoscopy is used to inspect for changes in the bronchial tree, not to assess for vascular changes. PET scans are most useful in determining the presence of malignancy.

Question 8

When the nurse is analyzing the results of a patient's arterial blood gases (ABGs), which finding indicates the need for most immediate action? A) The arterial oxygen saturation (SaO₂) is 92%. B) The partial pressure of oxygen in arterial blood (PaO₂) is 59 mm Hg. C) The partial pressure of CO₂ in arterial blood (PaCO₂) is 31 mm Hg. D) The bicarbonate level (HCO₃-) is 29 mEq/L.

Accepted Answer

All the values are abnormal, but the low PaO₂ indicates that the patient is at the point on the oxyhemoglobin dissociation curve where a small change in the PaO₂ will cause a large drop in the O₂ saturation and a decrease in tissue oxygenation. The nurse should intervene immediately to improve the patient's oxygenation.

Question 9

On auscultation of a patient's lungs, the nurse hears short, high-pitched sounds during exhalation in the lower 1/3 of both lungs. The nurse records this finding as&#10;A) expiratory crackles at the bases.&#10;B) expiratory wheezes in both lungs.&#10;C) abnormal lung sounds in the bases of both lungs.&#10;D) pleural friction rub in the right and left lower lobes.

Accepted Answer

Wheezes are high-pitched sounds. In this case they are heard during the expiratory phase of the respiratory cycle. Abnormal breath sounds are either bronchial or bronchovesicular sounds heard in the peripheral lung fields. Crackles are low-pitched, "bubbling" sounds. Pleural friction rubs are grating sounds that are usually heard during both inspiration and expiration.

Question 10

When preparing the patient with a right-sided pleural effusion for a thoracentesis, how will the nurse position the patient?&#10;A) Supine with the head of the bed elevated 45 degrees&#10;B) In the Trendelenburg position with both arms extended&#10;C) On the left side with the right arm extended above the head&#10;D) Sitting upright with the arms supported on an over bed table

Accepted Answer

The upright position with the arms supported increases lung expansion, allows fluid to collect at the lung bases, and expands the intercostal space so that access to the pleural space is easier. The other positions would increase the work of breathing for the patient and make it more difficult for the health care provider performing the thoracentesis.

Question 11

After the nurse has received change-of-shift report, which of these patients should be assessed first?&#10;A) A patient with pneumonia who has crackles in the right lung base&#10;B) A patient with chronic obstructive pulmonary disease ( COPD ) and pulmonary function testing ( PFT ) that indicates low forced vital capacity&#10;C) A patient with possible lung cancer who has just returned after bronchoscopy&#10;D) A patient with hemoptysis and a 16-mm induration with tuberculin skin testing

Accepted Answer

The answer of After the nurse has received change-of-shift report,...

Question 12

A patient is admitted with a metabolic acidosis of unknown origin. Based on this diagnosis, the nurse would expect the patient to have A) intercostal retractions. B) Kussmaul respirations. C) a low oxygen saturation (SpO₂). D) a decrease in venous O₂ pressure.

Accepted Answer

The answer of A patient is admitted with a metabolic...

Question 13

A hypothermic patient is admitted to the emergency department, and pulse oximetry (SpO₂) indicates that the O₂ saturation is 96%. Which action should the nurse take next? A) Initiate rewarming of the patient. B) Complete a head-to-toe assessment. C) Obtain arterial blood gases (ABGs). D) Place the patient on high-flow oxygen.

Accepted Answer

The answer of A hypothermic patient is admitted to the...

Question 14

The nurse obtains this information when assessing a patient with chronic obstructive pulmonary disease ( COPD ) who has been admitted with increasing dyspnea over the last 3 days. Which finding is most important to report to the health care provider?

A) Respirations are 36 breaths/minute.
B) Anterior-posterior chest ratio is 1:1.
C) Lung expansion is decreased bilaterally.
D) Hyperresonance to percussion is present.

Accepted Answer

The answer of The nurse obtains this information when assessing...

Question 15

A patient with a chronic cough has a bronchoscopy. Which action will be included in the nursing care plan after the procedure?&#10;A) Elevate the head of the bed to 80 to 90 degrees.&#10;B) Keep the patient NPO until the gag reflex returns.&#10;C) Place on bed rest for at least 4 hours postbronchoscopy.&#10;D) Notify the health care provider about blood-tinged mucus.

Accepted Answer

The answer of A patient with a chronic cough has...

Question 16

The nurse is observing a student who is listening to a patient's lungs. Which action by the student indicates a need to review respiratory assessment skills?&#10;A) The student compares breath sounds from side to side.&#10;B) The student listens only over the posterior part of the chest.&#10;C) The student places the stethoscope over the scapulae and then auscultates.&#10;D) The student starts at the base of the posterior lung and moves to the apices.

Accepted Answer

The answer of The nurse is observing a student who...

Question 17

Which action will the nurse plan to take for a patient who is scheduled for pulmonary function testing (PFT)?&#10;A) Explain reasons for NPO status.&#10;B) Administer sedative drug before PFT.&#10;C) Assess pulse and BP after the procedure.&#10;D) Teach deep inhalation and forceful exhalation.

Accepted Answer

The answer of Which action will the nurse plan to...

Question 18

A patient with acute dyspnea is scheduled for a spiral computed tomography (CT) scan. Which information obtained by the nurse is most important to communicate to the health care provider before the CT?

A) The apical pulse is 102.
B) The respiratory rate is 32.
C) The oxygen saturation is 93%.
D) The patient is allergic to shellfish.

Accepted Answer

The answer of A patient with acute dyspnea is scheduled...

Question 19

A patient with chronic hypoxemia ( SaO₂ levels of 89% to 90% ) caused by chronic obstructive pulmonary disease ( COPD ) has been hospitalized with increasing shortness of breath. In planning for discharge, which of these actions by the nurse will be most effective in improving compliance with discharge teaching?

A) Arrange for the patient's spouse to be present during the teaching.
B) Start giving the patient discharge teaching on the day of admission.
C) Accomplish the patient teaching just before the scheduled discharge.
D) Have the patient repeat the instructions immediately after the teaching.

Accepted Answer

The answer of A patient with chronic hypoxemia ( SaO₂...

Question 20

The nurse is admitting a patient who has a diagnosis of an acute asthma attack. Which information obtained by the nurse indicates that the patient may need teaching regarding medication use?&#10;A) The patient says there have been no acute asthma attacks during the last year.&#10;B) The patient became very short of breath an hour before coming to the hospital.&#10;C) The patient has been using the albuterol (Proventil) inhaler more frequently over the last 4 days.&#10;D) The patient has been taking acetaminophen (Tylenol) 650 mg every 6 hours for chest-wall pain.

Accepted Answer

The answer of The nurse is admitting a patient who...

Question 21

Which nursing actions will be included when sending a patient for computed tomography (CT) of the chest with contrast (select all that apply)?&#10;A) Ask the patient about any claustrophobia.&#10;B) Question the patient about allergies to iodine.&#10;C) Avoid administration of bronchodilator drugs.&#10;D) Have the patient remove wedding bands or any other jewelry.&#10;E) Review the recent blood urea nitrogen (BUN) and creatinine levels.

Accepted Answer

The answer of Which nursing actions will be included when...

Question 22

When performing an assessment of the patient's respiratory system, the nurse uses the following illustrated technique to evaluate  &#10;A) bronchophony.&#10;B) chest expansion.&#10;C) accessory muscle use.&#10;D) diaphragmatic excursion.

Accepted Answer

The answer of When performing an assessment of the patient's...

Deck 26: Nursing Assessment: Respiratory System