Question 1

A patient, age 22, is admitted with acute asthma. The patient shows a pulse oximetry level of SaO? of 82%. How should the nurse interpret this?

Accepted Answer

An SaO? indicates that only 82% of the available oxygen is bound to the hemoglobin.

Question 2

What is the appropriate nursing intervention for a patient, age 40, who is diagnosed with active tuberculosis?

Accepted Answer

If TB is suspected, permission to place the patient in acid-fast bacillus (AFB) Isolation Precautions should be requested immediately.

Question 3

How would the nurse examining a patient with pleurisy document a low-pitched grating lung sound?

Accepted Answer

A low-pitched grating sound in the presence of an inflammatory disorder is a friction rub.

Question 4

What is a major advantage of video assisted thoracoscopic surgery (VATS)?

Accepted Answer

The video assisted thoracoscopic surgery allows surgeons to remove tumors through a small keyhole incision. Although the incisions are small, a closed chest drainage system will still be necessary after the surgery.

Question 5

The patient has advanced emphysema and complains of dyspnea and fatigue. What would the most appropriate nursing intervention be for the nursing diagnosis of Activity intolerance related to an imbalance between the oxygen supply and demand?

Accepted Answer

Nursing interventions will be directed at attempting to decrease the patient's anxiety and promote optimal air exchange. The nurse should allow sufficient rest periods and should assist the patient in activities of daily living.

Question 6

Which instruction by the nurse is inappropriate for teaching the proper technique for collection of a sputum specimen?

Accepted Answer

Collecting specimens before meals will avoid possible emesis from coughing after eating.

Question 7

A nursing diagnosis for the patient with a new laryngectomy would be Social isolation related to impaired verbal communication related to removal of the larynx. What is an appropriate nursing intervention?

Accepted Answer

Provide patient with implements for communication. Rapidly completing care and provision of solitary activities does not reduce social isolation.

Question 8

When assessing the SaO? with a pulse oximeter, the nurse will place the oximeter on a finger:

Accepted Answer

The pulse oximeter should be placed on a finger of the hand that is normal temperature because hypothermia will affect the reading. The device should not be put on a finger on the same side as a blood pressure cuff or arterial line.

Question 9

What is inspiratory capacity?

Accepted Answer

Inspiratory capacity is the volume of air that can be inhaled in one breath from the resting expiratory level.

Question 10

What happens when there is a decrease in the oxygen level in the blood?

Accepted Answer

The chemoreceptors in the carotid bodies and the aortic bodies send a message to the respiratory centers to modify respirations.

Question 11

A 55-year-old man comes to the health nurse at his place of work with epistaxis. He reports he has frequent nosebleeds that he can usually control himself. What would be the most helpful assessment after the nurse has stopped the bleeding?

Accepted Answer

Check the blood pressure for hypotension to assess for hypovolemic shock. Adults can lose as much as 1 L of blood in an hour with heavy epistaxis.

Question 12

The patient with long-term emphysema is admitted with a secondary diagnosis of cor pulmonale. What should the nurse anticipate?

Accepted Answer

COPD can lead to cor pulmonale, an abnormal cardiac condition characterized by hypertrophy of the right ventricle of the heart as a result of hypertension of the pulmonary circulation. Cor pulmonale results in the presence of edema in the lower extremities, as well as in the sacral and perineal area, distended neck veins, and enlargement of the liver with ascites.

Question 13

The nurse assessing an 11-year-old who is having an asthma attack expects to hear adventitious sounds of:

Accepted Answer

The narrowed bronchioles characteristic of an asthma attack would produce sibilant wheezes, which are high-pitched whistling sounds.

Question 14

How will the kidneys behave in respiratory acidosis?

Accepted Answer

In respiratory acidosis the pH is low. The kidneys will retain bicarbonate to increase the pH.

Question 15

A patient is on postoperative day 2 after undergoing a total hip replacement. The patient suddenly complains of chest pain and is coughing up blood-tinged sputum. What should be the nurse's initial intervention?

Accepted Answer

When a pulmonary embolus is suspected, the head of the bed should be elevated to facilitate respiration and oxygen is administered. The charge nurse and the physician should be notified, but only after the patient is stabilized and oxygenated.

Question 16

How should the newly diagnosed patient who has been prescribed isoniazid (INH) for the treatment of active tuberculosis (TB) be advised?

Accepted Answer

INH therapy is long term. The patient should be advised to get regular liver studies and report tingling and numbness of the extremities.

Question 17

An 83-year-old patient is admitted with a temperature of 102° F (38.8° C), chest pain, and fatigue. What is the infected fluid that the physician removes called?

Accepted Answer

If the fluid between the lung and the membrane lining the pleural cavity becomes infected, it is called empyema.

Question 18

A patient, age 69, has emphysema. On assessment, the nurse notes the presence of a "barrel chest." What does this pathology result from?

Accepted Answer

The patient will eventually appear barrel chested (an increased anteroposterior diameter caused by overinflation).

Question 19

What is the purpose of the cilia?

Accepted Answer

The cilia are fine hairlike processes on the outer surfaces of small cells that produce a motion that sweeps the debris toward the nasal cavity. Large particles that are swept away stimulate the cough reflex, but not the cilia themselves.

Question 20

What is true about activities such as walking for the patient with emphysema?

Accepted Answer

Aerobic exercises such as walking will increase the body's ability to use oxygen through sustained rhythmic contractions of large muscles.

Quiz 48: Care of the Patient with a Respiratory Disorder