Question 1

The nurse prepares a patient with a left-sided pleural effusion for a thoracentesis.How should the nurse position the patient?

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 2

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?

Accepted Answer

Hypoxemia interferes with the patient's ability to learn and retain information,so having the patient's caregiver present will increase the likelihood that discharge instructions will be followed.Having the patient repeat the instructions will indicate that the information is understood at the time,but it does not guarantee retention of the information.Because the patient is likely to be distracted just before discharge,giving discharge instructions just before discharge is not ideal.The patient is likely to be anxious and even more hypoxemic than usual on the day of admission,so teaching about discharge should be postponed.

Question 3

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?

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 4

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?

Accepted Answer

Kussmaul (deep and rapid)respirations are a compensatory mechanism for metabolic acidosis.The low pH and low bicarbonate result indicate metabolic acidosis.Intercostal retractions,a low oxygen saturation rate,and a decrease in venous O₂ pressure would not be caused by acidosis.

Question 5

The nurse teaches a patient about pulmonary function testing (PFT).Which statement,if made by the patient,indicates teaching was effective?

Accepted Answer

For PFT,the patient should inhale deeply and exhale as long,hard,and fast as possible.The other actions are not needed with PFT.The administration of inhaled bronchodilators should be avoided 6 hours before the procedure.

Question 6

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?

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 7

The nurse assesses 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 for the nurse to report to the health care provider?

Accepted Answer

The increase in respiratory rate indicates respiratory distress and a need for rapid interventions such as administration of oxygen or medications.The other findings are common chronic changes occurring in patients with COPD.

Question 8

When assessing the respiratory system of an older patient,which finding indicates that the nurse should take immediate action?

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

Question 9

A patient with a chronic cough has a bronchoscopy.After the procedure,which intervention by the nurse is most appropriate?

Accepted Answer

Risk for aspiration and maintaining an open airway is the priority.Because a local anesthetic is used to suppress the gag/cough reflexes during bronchoscopy,the nurse should monitor for the return of these reflexes before allowing the patient to take oral fluids or food.Blood-tinged mucus is not uncommon after bronchoscopy.The patient does not need to be on bed rest,and the head of the bed does not need to be in the high-Fowler's position.

Question 10

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?

Accepted Answer

The increased need for a rapid-acting bronchodilator should alert the patient that an acute attack may be imminent and that a change in therapy may be needed.The patient should be taught to contact a health care provider if this occurs.The other data do not indicate any need for additional teaching.

Question 11

The nurse analyzes the results of a patient's arterial blood gases (ABGs).Which finding would require immediate action?

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 12

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?

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 13

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?

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 14

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

Accepted Answer

Spiral computed tomography (CT)scans are the most commonly used test to diagnose pulmonary emboli,and contrast media may be given IV.A chest x-ray may be ordered but will not be diagnostic for a pulmonary embolus.Preparation for a chest x-ray includes undressing and removing any metal.Bronchoscopy is used to detect changes in the bronchial tree,not to assess for vascular changes,and the patient should be NPO 6 to 12 hours before the procedure.Positron emission tomography (PET)scans are most useful in determining the presence of malignancy,and a radioactive glucose preparation is used.

Question 15

The nurse palpates the posterior chest while the patient says "99" and notes absent fremitus.Which action should the nurse take next?

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 16

The nurse observes a student who is listening to a patient's lungs who is having no problems with breathing.Which action by the student indicates a need to review respiratory assessment skills?

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.If so,start at the bases (see Fig.26-7).Place the stethoscope over lung tissue,not over bony prominences.

Question 17

While caring for a patient with respiratory disease,the nurse observes that the patient's SpO₂ drops from 93% to 88% while the patient is ambulating in the hallway.What is the priority action of the nurse?

Accepted Answer

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

Question 18

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?

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.Rhonchi are continuous rumbling,snoring,or rattling sounds mainly on expiration.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 19

After the nurse has received change-of-shift report,which patient should the nurse assess first?

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 20

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 take next?

Accepted Answer

Although the O₂ saturation is adequate,the left shift in the oxyhemoglobin dissociation curve will decrease the amount of oxygen delivered to tissues,so high oxygen concentrations should be given.Bicarbonate would worsen the patient's condition.A head-to-toe assessment and repeat ABGs may be implemented.However,the priority intervention is to give high-flow oxygen.

Quiz 26: Nursing Assessment: Respiratory System

The nurse prepares a patient with a left-sided pleural effusion for a thoracentesis.How should the nurse position the patient?

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?

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?

The nurse teaches a patient about pulmonary function testing (PFT) .Which statement,if made by the patient,indicates teaching was effective?

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?

The nurse assesses 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 for the nurse to report to the health care provider?

When assessing the respiratory system of an older patient,which finding indicates that the nurse should take immediate action?

A patient with a chronic cough has a bronchoscopy.After the procedure,which intervention by the nurse is most appropriate?

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?

The nurse analyzes the results of a patient's arterial blood gases (ABGs) .Which finding would require immediate action?

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?

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?

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

The nurse palpates the posterior chest while the patient says "99" and notes absent fremitus.Which action should the nurse take next?

The nurse observes a student who is listening to a patient's lungs who is having no problems with breathing.Which action by the student indicates a need to review respiratory assessment skills?

While caring for a patient with respiratory disease,the nurse observes that the patient's SpO₂ drops from 93% to 88% while the patient is ambulating in the hallway.What is the priority action of the nurse?

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?

After the nurse has received change-of-shift report,which patient should the nurse assess first?

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 take next?

Quiz 26: Nursing Assessment: Respiratory System

The nurse prepares a patient with a left-sided pleural effusion for a thoracentesis.How should the nurse position the patient?

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?

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?

The nurse teaches a patient about pulmonary function testing (PFT) .Which statement,if made by the patient,indicates teaching was effective?

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?

The nurse assesses 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 for the nurse to report to the health care provider?

When assessing the respiratory system of an older patient,which finding indicates that the nurse should take immediate action?

A patient with a chronic cough has a bronchoscopy.After the procedure,which intervention by the nurse is most appropriate?

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?

The nurse analyzes the results of a patient's arterial blood gases (ABGs) .Which finding would require immediate action?

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?

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?

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

The nurse palpates the posterior chest while the patient says "99" and notes absent fremitus.Which action should the nurse take next?

The nurse observes a student who is listening to a patient's lungs who is having no problems with breathing.Which action by the student indicates a need to review respiratory assessment skills?

While caring for a patient with respiratory disease,the nurse observes that the patient's SpO2 drops from 93% to 88% while the patient is ambulating in the hallway.What is the priority action of the nurse?

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?

After the nurse has received change-of-shift report,which patient should the nurse assess first?

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 take next?

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?

While caring for a patient with respiratory disease,the nurse observes that the patient's SpO₂ drops from 93% to 88% while the patient is ambulating in the hallway.What is the priority action of the nurse?

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 take next?