Question 1

The nurse completes a shift assessment on a patient admitted in the early phase of heart failure. When auscultating the patient's lungs,which finding would the nurse most likely hear?&#10;A)Continuous rumbling, snoring, or rattling sounds mainly on expiration&#10;B)Continuous high-pitched musical sounds on inspiration and expiration&#10;C)Discontinuous, high-pitched sounds of short duration during inspiration&#10;D)A series of long-duration, discontinuous, low-pitched sounds during inspiration

Accepted Answer

Fine crackles are likely to be heard in the early phase of heart failure. Fine crackles are discontinuous,high-pitched sounds of short duration heard on inspiration. Course crackles are a series of long-duration,discontinuous,low-pitched sounds during inspiration. Wheezes are continuous high-pitched musical sounds on inspiration and expiration.

Question 2

A patient with acute dyspnea is scheduled for a spiral computed tomography (CT)scan. Which information obtained by the nurse is a priority to communicate to the health care provider before the CT?&#10;A)Allergy to shellfish&#10;B)Apical pulse of 104&#10;C)Respiratory rate of 30&#10;D)O2 saturation of 90%

Accepted Answer

Because iodine-based contrast media is used during a spiral CT,the patient may need to have the CT scan without contrast or be premedicated before injection of the contrast media. The increased pulse,low oxygen saturation,and tachypnea all indicate a need for further assessment or intervention but do not indicate a need to modify the CT procedure.

Question 3

On auscultation of a patient's lungs,the nurse hears low-pitched,bubbling sounds during inhalation in the lower third of both lungs. How should the nurse document this finding?&#10;A)Inspiratory crackles at the bases&#10;B)Expiratory wheezes in both lungs&#10;C)Abnormal lung sounds in the apices of both lungs&#10;D)Pleural friction rub in the right and left lower lobes

Accepted Answer

Crackles are low-pitched,bubbling sounds usually heard on inspiration. Wheezes are high-pitched sounds. They can be heard during the expiratory or inspiratory phase of the respiratory cycle. The lower third of both lungs are the bases,not apices. Pleural friction rubs are grating sounds that are usually heard during both inspiration and expiration.

Question 4

After the nurse has received change-of-shift report,which patient should the nurse assess first?&#10;A)A patient with pneumonia who has crackles in the right lung base&#10;B)A patient with chronic bronchitis who has a 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 after tuberculin skin testing

Accepted Answer

Because the cough and gag are decreased after bronchoscopy,this patient should be assessed for airway patency. The other patients do not have clinical manifestations or procedures that require immediate assessment by the nurse.

Question 5

Which assessment finding indicates that the nurse should take immediate action for an older patient?&#10;A)Weak cough effort&#10;B)Barrel-shaped chest&#10;C)Dry mucous membranes&#10;D)Bilateral basilar crackles

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 O? 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. An older patient has a less forceful cough and fewer and less functional cilia. Mucous membranes tend to be drier.

Question 6

The nurse analyzes the results of a patient's arterial blood gases (ABGs). Which finding would require immediate action? A)The bicarbonate level (HCO₃-) is 31 mEq/L. B)The arterial oxygen saturation (SaO₂) is 92%. C)The partial pressure of CO₂ in arterial blood (PaCO₂) is 31 mm Hg. D)The partial pressure of oxygen in arterial blood (PaO₂) is 59 mm Hg.

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 7

The nurse observes 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 at each level.&#10;B)The student listens during the inspiratory phase, then moves the stethoscope.&#10;C)The student starts at the apices of the lungs, moving down toward the lung bases.&#10;D)The student instructs the patient to breathe slowly and deeply through the mouth.

Accepted Answer

Listening only during inspiration indicates the student needs a review of respiratory assessment skills. At each placement of the stethoscope,listen to at least one cycle of inspiration and expiration. During chest auscultation,instruct the patient to breathe slowly and a little deeper than normal through the mouth. Auscultation should proceed from the lung apices to the bases,comparing opposite areas of the chest,unless the patient is in respiratory distress or will tire easily.

Question 8

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)Ask the patient to lie down to complete a full physical assessment.&#10;B)Briefly ask specific questions about this episode of respiratory distress.&#10;C)Complete the admission database to check for allergies before treatment.&#10;D)Delay the physical assessment to first complete pulmonary function tests.

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. Brief questioning and a focused physical assessment should be done rapidly to help determine the cause of the distress and suggest treatment. Checking for allergies is important,but it is not appropriate to complete the entire admission database at this time. The initial respiratory assessment must be completed before any diagnostic tests or interventions can be ordered.

Question 9

The nurse palpates the posterior chest while the patient says &#34;99&#34; and notes absent fremitus. Which action should the nurse take next?&#10;A)Palpate the anterior chest and observe for barrel chest.&#10;B)Encourage the patient to turn, cough, and deep breathe.&#10;C)Review the chest x-ray report for evidence of pneumonia.&#10;D)Auscultate anterior and posterior breath sounds bilaterally.

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." After noting absent fremitus,the nurse should then auscultate the lungs to assess for the presence or absence of breath sounds. Absent fremitus may be noted with pneumothorax or atelectasis. The vibration is increased in conditions such as pneumonia,lung tumors,thick bronchial secretions,and pleural effusion. Turning,coughing,and deep breathing is an appropriate intervention for atelectasis,but the nurse needs to first assess breath sounds. Fremitus is decreased if the hand is farther from the lung or the lung is hyperinflated (barrel chest). The anterior of the chest is more difficult to palpate for fremitus because of the presence of large muscles and breast tissue.

Question 10

The nurse observes that a patient with respiratory disease experiences a decrease in SpO₂ from 93% to 88% while the patient is ambulating. What is the priority action of the nurse? A)Notify the health care provider. B)Administer PRN supplemental O₂. C)Document the response to exercise. D)Encourage the patient to pace activity.

Accepted Answer

The drop in SpO₂ to 85% indicates that the patient is hypoxemic and needs supplemental O₂ when exercising. The other actions are also important,but the first action should be to correct the hypoxemia.

Question 11

The nurse teaches a patient about pulmonary spirometry testing. Which statement,if made by the patient,indicates teaching was effective?&#10;A)&#34;I should use my inhaler right before the test.&#34;&#10;B)&#34;I won't eat or drink anything 8 hours before the test.&#34;&#10;C)&#34;I will inhale deeply and blow out hard during the test.&#34;&#10;D)&#34;My blood pressure and pulse will be checked every 15 minutes.&#34;

Accepted Answer

The answer of The nurse teaches a patient about pulmonary...

Question 12

A patient admitted to the emergency department complaining of sudden onset shortness of breath is diagnosed with a possible pulmonary embolus. How should the nurse prepare the patient for diagnostic testing to confirm the diagnosis?

A)Ensure that the patient has been NPO.
B)Start an IV so contrast media may be given.
C)Inform radiology that radioactive glucose preparation is needed.
D)Instruct the patient to expect to inspire deeply and exhale forcefully.

Accepted Answer

The answer of A patient admitted to the emergency department...

Question 13

The nurse admits a patient who has a diagnosis of an acute asthma attack. Which statement indicates that the patient may need teaching regarding medication use?&#10;A)&#34;I have not had any acute asthma attacks during the past year.&#34;&#10;B)&#34;I became short of breath an hour before coming to the hospital.&#34;&#10;C)&#34;I've been taking Tylenol 650 mg every 6 hours for chest wall pain.&#34;&#10;D)&#34;I've been using my albuterol inhaler more frequently over the last 4 days.&#34;

Accepted Answer

The answer of The nurse admits a patient who has...

Question 14

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

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

Accepted Answer

The answer of A patient who has a history of...

Question 15

A patient in metabolic alkalosis is admitted to the emergency department and pulse oximetry (SpO₂)indicates that the O₂ saturation is 94%. Which action should the nurse expect to take next? A)Complete a head-to-toe assessment. B)Administer an inhaled bronchodilator. C)Place the patient on high-flow oxygen. D)Obtain repeat arterial blood gases (ABGs).

Accepted Answer

The answer of A patient in metabolic alkalosis is admitted...

Question 16

The laboratory has just called with the arterial blood gas (ABG)results on four patients. Which result is most important for the nurse to report immediately to the health care provider?&#10;A)pH 7.34, PaO2 82 mm Hg, PaCO2 40 mm Hg, and O2 sat 97%&#10;B)pH 7.35, PaO2 85 mm Hg, PaCO2 50 mm Hg, and O2 sat 95%&#10;C)pH 7.46, PaO2 90 mm Hg, PaCO2 32 mm Hg, and O2 sat 98%&#10;D)pH 7.31, PaO2 91 mm Hg, PaCO2 50 mm Hg, and O2 sat 96%

Accepted Answer

The answer of The laboratory has just called with the...

Question 17

The nurse prepares a patient with a left-sided pleural effusion for a thoracentesis. How should the nurse position the patient?&#10;A)High-Fowler's position with the left arm extended&#10;B)Supine with the head of the bed elevated 30 degrees&#10;C)On the right side with the left arm extended above the head&#10;D)Sitting upright with the arms supported on an over bed table

Accepted Answer

The answer of The nurse prepares a patient with a...

Question 18

A patient with a chronic cough is scheduled to have a bronchoscopy with biopsy. Which intervention will the nurse implement directly after the procedure?&#10;A)Encourage the patient to drink clear liquids.&#10;B)Place the patient on bed rest for at least 4 hours.&#10;C)Keep the patient NPO until the gag reflex returns.&#10;D)Maintain the head of the bed elevated 90 degrees.

Accepted Answer

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

Question 19

The nurse assesses a patient with chronic obstructive pulmonary disease (COPD)who has been admitted with increasing dyspnea over the past 3 days. Which finding is important for the nurse to report to the health care provider?

A)Respirations are 36 breaths/min.
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 assesses a patient with chronic...

Question 20

A diabetic patient's arterial blood gas (ABG)results are pH 7.28; PaCO₂ 34 mm Hg; PaO₂ 85 mm Hg; HCO₃- 18 mEq/L. The nurse would expect which finding? A)Intercostal retractions B)Kussmaul respirations C)Low oxygen saturation (SpO₂) D)Decreased venous O₂ pressure

Accepted Answer

The answer of A diabetic patient's arterial blood gas (ABG)results...

Question 21

Using the illustrated technique,the nurse is assessing for which finding in a patient with chronic obstructive pulmonary disease (COPD)?  &#10;A)Hyperresonance&#10;B)Tripod positioning&#10;C)Reduced excursion&#10;D)Accessory muscle use

Accepted Answer

The answer of Using the illustrated technique,the nurse is assessing...

Question 22

While listening to the posterior chest of a patient who is experiencing acute shortness of breath,the nurse hears these sounds. How should the nurse document the lung sounds? HYPERLINK "http://static.us.elsevierhealth.com/lewis_9e/wheezing.mp3" Click here to listen to the audio clip

A)Pleural friction rub
B)Low-pitched crackles
C)High-pitched wheezes
D)Bronchial breath sounds

Accepted Answer

The answer of While listening to the posterior chest of...

Question 23

Which action is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)?&#10;A)Listen to a patient's lung sounds for wheezes or crackles.&#10;B)Label specimens obtained during percutaneous lung biopsy.&#10;C)Instruct a patient about how to use home spirometry testing.&#10;D)Measure induration at the site of a patient's intradermal skin test.

Accepted Answer

The answer of Which action is appropriate for the nurse...

Question 24

A patient is scheduled for a computed tomography (CT)scan of the chest with contrast media. Which assessment findings should the nurse report to the health care provider before the patient goes for the CT ?

A)Allergy to shellfish
B)Patient reports claustrophobia
C)Elevated serum creatinine level
D)Recent bronchodilator inhaler use
E)Inability to remove a wedding band

Accepted Answer

The answer of A patient is scheduled for a computed...

Deck 25: Assessment of Respiratory System