Chapter 25: Assessment of Respiratory System (cumulative 10%)

10. Which assessment finding of the respiratory system does the nurse interpret as normal? a. Inspiratory chest expansion of 1 inch. b. begin listening to the lung bases. c. Resonance (to percussion) over the lung bases d. Bronchial breath sounds in the lower lung fields.

10. Correct answer: d Rationale: Vesicular breath sounds are most commonly auscultated over the peripheral lung fields. Bronchial or bronchovesicular sounds heard in the peripheral lung fields would be abnormal.

The nurse is preparing the patient for a diagnostic procedure to remove pleural fluid for analysis. The nurse would prepare the patient for which test? a. Thoracentesis b. Bronchoscopy c. Pulmonary angiography d. Sputum culture and sensitivity

11. Correct answer: a Rationale: Thoracentesis is the insertion of a large-bore needle through the chest wall into the pleural space to obtain specimens for diagnostic evaluation, remove pleural fluid, or instill medication. conclusion of end of chapters Lewis practice questions.

2. A patient with a respiratory condition asks, "How does air get into my lungs?" The nurse bases her answer on knowledge that air moves into the lungs because of: a. increased CO2 and decreased O2 in blood. b. contraction of the accessory abdominal muscles c. stimulation of the respiratory muscles by the chemorecptors d. decrease in intrathoracic pressure relative to pressure at the airway.

2. Correct answer: d Rationale: During inspiration, the diaphragm contracts, moves downward, and increases intrathoracic volume. At the same time, the external intercostal muscles and scalene muscles contract, increasing the lateral and anteroposterior dimension of the chest. This causes the size of the thoracic cavity to increase and intrathoracic pressure to decrease, so air is pulled into the lungs.

3. The nurse can best determine adequate arterial oxygenation of the blood by assessing a. heart rate. b. hemoglobin level. c. arterial oxygen partial pressure. d. arterial carbon dioxide partial pressure.

3. Correct answer: c Rationale: The ability of the lungs to oxygenate arterial blood adequately is determined by examination of the partial pressure of oxygen in arterial blood (PaO2) and arterial oxygen saturation (SaO2).

4. When teaching a patient about the most important respiratory defense mechanism distal to the respiratory bronchioles, which topic would the nurse discuss? a. Alveolar macrophages b. Impaction of particles c. Reflex bronchoconstriction d. Mucociliary clearance mechanism

4. Correct answer: a Rationale: Respiratory defense mechanisms are efficient in protecting the lungs from inhaled particles, microorganisms, and toxic gases. Because ciliated cells are not found below the level of the respiratory bronchioles, the primary defense mechanism at the alveolar level is alveolar macrophages.

5. A student nurse asks the RN what can be measured by arterial blood gas (ABG). The RN tells the student that the ABG can measure (select all that apply): a. acid-base balance b. oxygenation status c. acidity of the blood. d. bicarbonate (HCO3) in arterial blood. e. overall balance of electrolytes

5. Correct answers: a, b, c, d Rationale: Arterial blood gases (ABGs) are measured to determine oxygenation status, ventilation status, and acid-base balance. ABG analysis includes measurement of the partial pressure of oxygen in arterial blood (PaO2), partial pressure of carbon dioxide in arterial blood (PaCO2), acidity (pH), bicarbonate (HCO3-), and arterial oxygen saturation (SaO2) in arterial blood. The overall balance of electrolytes cannot be determined with ABGs.

6. To detect early signs or symptoms of inadequate oxygenation, the nurse would examine the patient for: a. dyspnea and hypotension. b. apprehension and restlessness c. cyanosis and cool, clammy skin d. increased urine output and diaphoresis

6. Correct answer: b Rationale: Early symptoms of inadequate oxygenation include unexplained restlessness, apprehension, and irritability.

7. During the respiratory assessment of an older adult, the nurse would expect to find (select all that apply) a. a vigorous reflex cough. b. increased chest expansion. c. increased residual volume. d. diminished lung sounds at base of lungs. e. increased anteroposterior (AP) chest diameter.

7. Correct answers: c, d, e Rationale: The anterior-posterior diameter of the thoracic cage and the residual volume increase in older adults. An older adult has a less forceful cough. The costal cartilages calcify with aging and interfere with chest expansion. Decreased breath sounds at the base of lungs is also a common finding in older adults.

8. When assessing activity-exercise patterns related to respiratory health, the nurse inquires about: a. dyspnea during rest or exercise. b. recent weight loss or weight gain c. ability to sleep through the entire night. d. willingness to wear O2 equipment in public.

8. Correct answer: a Rationale: In this functional health pattern, determine whether the patient's activity is limited by dyspnea at rest or during exercise.

9. When auscultating the chest of an older patient in respiratory distress, it is best to a. begin listening at the apices. b. begin listening at the lung bases. c. begin listening on the anterior chest. d. Ask the patient to breathe through the nose with the mouth closed.

9. Correct answer: b Rationale: Normally, auscultation should proceed from the lung apices to the bases so that opposite areas of the chest are compared. If the patient is likely to tire easily or has respiratory distress, start at the bases.

20. 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.

ANS: A The increase in respiratory rate indicates respiratory distress and a need for rapid interventions such as administration of O2 or medications. The other findings are common chronic changes occurring in patients with COPD. DIF: Cognitive Level: Apply (application) REF: 460 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

Question 15 of 21 Which patient is exhibiting an early clinical manifestation of hypoxemia? A. A 48-yr-old patient who is intoxicated and acutely disoriented to time and place B. A 67-yr-old patient who has dyspnea while resting in the bed or in a reclining chair C. A 72-yr-old patient who has four new premature ventricular contractions per minute D. A 94-yr-old patient who has renal insufficiency, anemia, and decreased urine output

ANS: A 72-yr-old patient who has four new premature ventricular contractions per minute Early clinical manifestations of hypoxemia include dysrhythmias (e.g., premature ventricular contractions), unexplained decreased level of consciousness (e.g., disorientation), dyspnea on exertion, and unexplained decreased urine output. INCORRECT A 67-yr-old patient who has dyspnea while resting in the bed or in a reclining chair

MULTIPLE RESPONSE 1. 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 (select all that apply)? 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

ANS: A, C Because the contrast media is iodine based and may cause dehydration and decreased renal blood flow, asking about iodine allergies (such as allergy to shellfish) and monitoring renal function before the CT scan are necessary. The other actions are not contraindications for CT of the chest, although they may be for other diagnostic tests, such as magnetic resonance imaging or pulmonary spirometry. DIF: Cognitive Level: Apply (application) REF: 470 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

Question 6 of 21 The nurse is interpreting a tuberculin skin test (TST) for a 58-yr-old female patient with end-stage renal disease secondary to diabetes mellitus. Which finding would indicate a positive reaction? A. Acid-fast bacilli cultured at the injection site B. 15-mm area of redness at the TST injection site C. 11-mm area of induration at the TST injection site D. Wheal formed immediately after intradermal injection

ANS: 11-mm area of induration at the TST injection site An area of induration 10 mm or larger would be a positive reaction in a person with end-stage renal disease. Reddened, flat areas do not indicate a positive reaction. A wheal appears when the TST is administered that indicates correct administration of the intradermal antigen. Presence of acid-fast bacilli in the sputum indicates active tuberculosis.

Question 8 of 21 The nurse is caring for a patient with chronic obstructive pulmonary disorder (COPD) and pneumonia who has an order for arterial blood gases to be drawn. What is the minimum length of time the nurse should plan to hold pressure on the puncture site? A. 2 minutes B. 5 minutes C. 10 minutes D. 15 minutes

ANS: 5 minutes After obtaining blood for an arterial blood gas measurement, the nurse should hold pressure on the puncture site for 5 minutes by the clock to be sure that bleeding has stopped. An artery is an elastic vessel under much higher pressure than veins, and significant blood loss or hematoma formation could occur if the time is insufficient.

14. 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. Allergy to shellfish b. Apical pulse of 104 c. Respiratory rate of 30 d. O2 saturation of 90%

ANS: A 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. DIF: Cognitive Level: Analyze (analysis) REF: 470 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

4. 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? a. Inspiratory crackles at the bases b. Expiratory wheezes in both lungs c. Abnormal lung sounds in the apices of both lungs d. Pleural friction rub in the right and left lower lobes

ANS: A 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. DIF: Cognitive Level: Apply (application) REF: 468 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

When assessing a patient's sleep-rest pattern related to respiratory health, what should the nurse ask the patient (select all that apply.)? A. Do you awaken abruptly during the night? B. Do you sleep more than 8 hours per night? C. Do you need to sleep with the head elevated? D. Do you often need to urinate during the night? E. Do you toss and turn when trying to fall asleep?

ANS: A, C, E Rationale: A patient with obstructive sleep apnea may have insomnia, abrupt awakenings, or both. Patients with cardiovascular disease (e.g., heart failure that may affect respiratory health) may need to sleep with the head elevated on several pillows (orthopnea). Sleeping more than 8 hours per night or needing to urinate during the night is not indicative of impaired respiratory health. Do you need to sleep with the head elevated? A patient with obstructive sleep apnea may have insomnia, abrupt awakenings, or both. Patients with cardiovascular disease (e.g., heart failure that may affect respiratory health) may need to sleep with the head elevated on several pillows (orthopnea). Sleeping more than 8 hours per night or needing to urinate during the night is not indicative of impaired respiratory health Do you toss and turn when trying to fall asleep? A patient with obstructive sleep apnea may have insomnia, abrupt awakenings, or both. Patients with cardiovascular disease (e.g., heart failure that may affect respiratory health) may need to sleep with the head elevated on several pillows (orthopnea). Sleeping more than 8 hours per night or needing to urinate during the night is not indicative of impaired respiratory health.

Question 5 of 21 The patient is hospitalized with pneumonia. Which diagnostic test should be used to measure the efficiency of gas exchange in the lung and tissue oxygenation? A. Thoracentesis B. Bronchoscopy C. Arterial blood gases D. Pulmonary function tests

ANS: Arterial blood gases Arterial blood gases are used to assess the efficiency of gas exchange in the lung and tissue oxygenation as is pulse oximetry. Thoracentesis is used to obtain specimens for diagnostic evaluation, remove pleural fluid, or instill medication into the pleural space. Bronchoscopy is used for diagnostic purposes, to obtain biopsy specimens, and to assess changes resulting from treatment. Pulmonary function tests measure lung volumes and airflow to diagnose pulmonary disease, monitor disease progression, evaluate disability, and evaluate response to bronchodilators.

Question 11 of 21 The patient with Parkinson's disease has a pulse oximetry reading of 72%, but he is not displaying any other signs of decreased oxygenation. What is most likely contributing to his low SpO2 level? A. Artifact B. Anemia C. Dark skin color D. Thick acrylic nails

ANS: Artifact Motion is the most likely cause of the low SpO2 for this patient with Parkinson's disease. Anemia, dark skin color, and thick acrylic nails as well as low perfusion, bright fluorescent lights, and intravascular dyes may also cause an inaccurate pulse oximetry result. There is no mention of these or reason to suspect these in this question. INCORRECT: Anemia Motion is the most likely cause of the low SpO2 for this patient with Parkinson's disease. Anemia, dark skin color, and thick acrylic nails as well as low perfusion, bright fluorescent lights, and intravascular dyes may also cause an inaccurate pulse oximetry result. There is no mention of these or reason to suspect these in this question.

Question 2 of 21 The nurse is obtaining a focused respiratory assessment of a 44-yr-old female patient who is in severe respiratory distress 2 days after abdominal surgery. What is most important for the nurse to assess? A. Auscultation of bilateral breath sounds B. Percussion of anterior and posterior chest wall C. Palpation of the chest bilaterally for tactile fremitus D. Inspection for anterior and posterior chest expansion

ANS: Auscultation of bilateral breath sounds Important assessments obtained during a focused respiratory assessment include auscultation of lung (breath) sounds. Assessment of tactile fremitus has limited value in acute respiratory distress. It is not necessary to assess for both anterior and posterior chest expansion. Percussion of the chest wall is not essential in a focused respiratory assessment.

3. 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

ANS: B 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. DIF: Cognitive Level: Apply (application) REF: 467 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

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

ANS: B Labeling of specimens is within the scope of practice of UAP. The other actions require nursing judgment and should be done by licensed nursing personnel. DIF: Cognitive Level: Apply (application) REF: 471 OBJ: Special Questions: Delegation TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment

10. 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? a. The student compares breath sounds from side to side at each level. b. The student listens during the inspiratory phase, then moves the stethoscope. c. The student starts at the apices of the lungs, moving down toward the lung bases. d. The student instructs the patient to breathe slowly and deeply through the mouth.

ANS: B 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. DIF: Cognitive Level: Apply (application) REF: 466 TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment

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.

ANS: B Spiral computed tomography scans are the most commonly used test to diagnose pulmonary emboli and contrast media may be given IV. 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 scans are most useful in determining the presence of malignancy and a radioactive glucose preparation is used. For spirometry, the patient is asked to inhale deeply and exhale as long, hard, and fast as possible. DIF: Cognitive Level: Apply (application) REF: 470 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

8. 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.

ANS: B 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. DIF: Cognitive Level: Analyze (analysis) REF: 459 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

1. 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. Ask the patient to lie down to complete a full physical assessment. b. Briefly ask specific questions about this episode of respiratory distress. c. Complete the admission database to check for allergies before treatment. d. Delay the physical assessment to first complete pulmonary function tests.

ANS: B 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. DIF: Cognitive Level: Apply (application) REF: 459 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

Question 14 of 21 In assessment of the patient with acute respiratory distress, what should the nurse expect to observe (select all that apply.)? A. Cyanosis B. Tripod position C. Kussmaul respirations D. Accessory muscle use E. Increased AP diameter

ANS: B, D RATIONALE: Tripod position, Accessory muscle use, Tripod position and accessory muscle use indicate moderate to severe respiratory distress. Cyanosis may be related to anemia, decreased oxygen transfer in the lungs, or decreased cardiac output. Therefore, it is a nonspecific and unreliable indicator of only respiratory distress. Kussmaul respirations occur when the patient is in metabolic acidosis to increase CO2 excretion. Increased AP diameter occurs with lung hyperinflation from chronic obstructive pulmonary disease, cystic fibrosis, or with advanced age. INCORRECT: Cyanosis

Question 4 of 21 A frail 82-yr-old female patient develops sudden shortness of breath while sitting in a chair. What location on the chest should the nurse begin auscultation of the lung fields? A. Bases of the posterior chest area B. Apices of the posterior lung fields C. Anterior chest area above the breasts D. Midaxillary on the left side of the chest

ANS: Bases of the posterior chest area Baseline data with the most information is best obtained by auscultation of the posterior chest, especially in female patients because of breast tissue interfering with the assessment or if the patient may tire easily (e.g., shortness of breath, dyspnea, weakness, fatigue). Usually auscultation proceeds from the lung apices to the bases unless it is possible the patient will tire easily. In this case, the nurse should start at the bases. INCORRECT: Anterior chest area above the breasts

OTHER 1. 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? https://www.youtube.com/watch?v=0W5R4UqdkWE Click here to listen to the audio clip a. Pleural friction rub b. Low-pitched crackles c. High-pitched wheezes d. Bronchial breath sounds

ANS: C Wheezes are continuous high-pitched or musical sounds heard initially with expiration. The other responses are typical of other adventitious breath sounds. DIF: Cognitive Level: Understand (comprehension) REF: 468 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

17. 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).

ANS: C Although the O2 saturation is adequate, the left shift in the oxyhemoglobin dissociation curve will decrease the amount of O2 delivered to tissues, so high oxygen concentrations should be given. A head-to-toe assessment and repeat ABGs may be implemented later. Bronchodilators are not needed for metabolic alkalosis and there is no indication that the patient is having difficulty with airflow. DIF: Cognitive Level: Analyze (analysis) REF: 457 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

18. After the nurse has received change-of-shift report, which patient should the nurse assess first? a. A patient with pneumonia who has crackles in the right lung base b. A patient with chronic bronchitis who has a low forced vital capacity c. A patient with possible lung cancer who has just returned after bronchoscopy d. A patient with hemoptysis and a 16-mm induration after tuberculin skin testing

ANS: C 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. DIF: Cognitive Level: Analyze (analysis) REF: 463 OBJ: Special Questions: Prioritization | Special Questions: Multiple Patients TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment

7. 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? a. Continuous rumbling, snoring, or rattling sounds mainly on expiration b. Continuous high-pitched musical sounds on inspiration and expiration c. Discontinuous, high-pitched sounds of short duration during inspiration d. A series of long-duration, discontinuous, low-pitched sounds during inspiration

ANS: C 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. DIF: Cognitive Level: Apply (application) REF: 468 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

9. The nurse teaches a patient about pulmonary spirometry testing. Which statement, if made by the patient, indicates teaching was effective? a. "I should use my inhaler right before the test." b. "I won't eat or drink anything 8 hours before the test." c. "I will inhale deeply and blow out hard during the test." d. "My blood pressure and pulse will be checked every 15 minutes."

ANS: C For spirometry, the patient should inhale deeply and exhale as long, hard, and fast as possible. The other actions are not needed. The administration of inhaled bronchodilators should be avoided 6 hours before the procedure. DIF: Cognitive Level: Apply (application) REF: 472 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

11. 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.

ANS: C 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. DIF: Cognitive Level: Analyze (analysis) REF: 462 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

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

ANS: C Risk for aspiration and maintaining an open airway is the priority. Because a local anesthetic is used to suppress the gag and cough reflexes during bronchoscopy, the nurse should monitor for the return of these reflexes before allowing the patient to take oral fluids or food. 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. DIF: Cognitive Level: Apply (application) REF: 470 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

21. Using the illustrated technique, the nurse is assessing for which finding in a patient with chronic obstructive pulmonary disease (COPD)? https://www.flickr.com/photos/162774456@N03/33513082578/in/dateposted-public/ a. Hyperresonance b. Tripod positioning c. Reduced excursion d. Accessory muscle use

ANS: C The technique for palpation for chest excursion is shown in the illustrated technique. Reduced chest movement would be noted on palpation of a patient's chest with COPD. Hyperresonance would be assessed through percussion. Accessory muscle use and tripod positioning would be assessed by inspection. DIF: Cognitive Level: Understand (comprehension) REF: 467 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

Question 3 of 21 The nurse, when auscultating the lower lungs of the patient, hears these breath sounds. How should the nurse document these sounds? https://www.youtube.com/watch?v=kwbOphK_3Tc A. Stridor B. Vesicular C. Coarse crackles D. Bronchovesicular

ANS: Coarse crackles Coarse crackles are a series of long-duration, discontinuous, low-pitched sounds caused by air passing through an airway intermittently occluded by mucus, an unstable bronchial wall, or a fold of mucosa. Coarse crackles are evident on inspiration and at times expiration. Stridor is a continuous crowing sound of constant pitch from partial obstruction of larynx or trachea. Vesicular sounds are relatively soft, low-pitched, gentle, rustling sounds. They are heard over all lung areas except the major bronchi. Bronchovesicular sounds are normal sounds heard anteriorly over the mainstem bronchi on either side of the sternum and posteriorly between the scapulae with a medium pitch and intensity

Question 18 of 21 The patient is calling the clinic with a cough. What assessment should be made first before the nurse advises the patient? A. Frequency, family history, hematemesis B. Weight loss, activity tolerance, orthopnea C. Cough sound, sputum production, pattern D. Smoking status, medications, residence location

ANS: Cough sound, sputum production, pattern The sound of the cough, sputum production and description, and the pattern of the cough's occurrence (including acute or chronic) and what its occurrence is related to are the first assessments to be made to determine the severity. Frequency of the cough will not provide a lot of information. Family history can help to determine a genetic cause of the cough. Hematemesis is vomiting blood and not as important as hemoptysis. Smoking is an important risk factor for chronic obstructive pulmonary disease, and lung cancer and may cause a cough. Medications may or may not contribute to a cough as does residence location. Weight loss, activity intolerance, and orthopnea may be related to respiratory or cardiac problems, but are not as important when dealing with a cough.

15. 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.

ANS: D 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. DIF: Cognitive Level: Analyze (analysis) REF: 457 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

16. Which assessment finding indicates that the nurse should take immediate action for an older patient? a. Weak cough effort b. Barrel-shaped chest c. Dry mucous membranes d. Bilateral basilar crackles

ANS: D 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 O2 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. DIF: Cognitive Level: Analyze (analysis) REF: 468 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

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? a. "I have not had any acute asthma attacks during the past year." b. "I became short of breath an hour before coming to the hospital." c. "I've been taking Tylenol 650 mg every 6 hours for chest wall pain." d. "I've been using my albuterol inhaler more frequently over the last 4 days."

ANS: D 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. DIF: Cognitive Level: Apply (application) REF: 460 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

2. The nurse prepares a patient with a left-sided pleural effusion for a thoracentesis. How should the nurse position the patient? a. High-Fowler's position with the left arm extended b. Supine with the head of the bed elevated 30 degrees c. On the right side with the left arm extended above the head d. Sitting upright with the arms supported on an over bed table

ANS: D 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. DIF: Cognitive Level: Apply (application) REF: 471 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

19. 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. pH 7.34, PaO2 82 mm Hg, PaCO2 40 mm Hg, and O2 sat 97% b. pH 7.35, PaO2 85 mm Hg, PaCO2 50 mm Hg, and O2 sat 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%

ANS: D These ABGs indicate uncompensated respiratory acidosis and should be reported to the health care provider. The other values are normal, close to normal, or compensated. DIF: Cognitive Level: Analyze (analysis) REF: 456 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

5. The nurse palpates the posterior chest while the patient says "99" and notes absent fremitus. Which action should the nurse take next? a. Palpate the anterior chest and observe for barrel chest. b. Encourage the patient to turn, cough, and deep breathe. c. Review the chest x-ray report for evidence of pneumonia. d. Auscultate anterior and posterior breath sounds bilaterally.

ANS: D 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. DIF: Cognitive Level: Apply (application) REF: 464 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

Question 12 of 21 After swallowing, a 73-yr-old patient is coughing and has a wet voice. What changes of aging could be contributing to this abnormal finding? A. Decreased response to hypercapnia B. Decreased number of functional alveoli C. Increased calcification of costal cartilage D. Decreased respiratory defense mechanisms

ANS: Decreased respiratory defense mechanisms These manifestations are associated with aspiration, which more easily occur in the right lung as the right mainstem bronchus is shorter, wider, and straighter than the left mainstem bronchus. Aspiration occurs more easily in the older patient related to decreased respiratory defense mechanisms (e.g., decreases in immunity, ciliary function, cough force, sensation in pharynx). Changes of aging include a decreased response to hypercapnia, decreased number of functional alveoli, and increased calcification of costal cartilage, but these do not increase the risk of aspiration. INCORRECT: Decreased number of functional alveoli

Question 19 of 21 What should the nurse inspect when assessing a patient with shortness of breath for evidence of long-standing hypoxemia? A. Fingernails B. Chest excursion C. Spinal curvatures D. Respiratory pattern

ANS: Fingernails Clubbing, a sign of long-standing hypoxemia, is evidenced by an increase in the angle between the base of the nail and fingernail to 180 degrees or more, usually accompanied by an increase in the depth, bulk, and sponginess of the end of the finger.

Question 16 of 21 When the patient is experiencing metabolic acidosis secondary to type 1 diabetes mellitus, what physiologic response should the nurse expect to assess in the patient? A. Vomiting B. Increased urination C. Decreased heart rate D. Increased respiratory rate

ANS: Increased respiratory rate When a patient with type 1 diabetes has hyperglycemia and ketonemia causing metabolic acidosis, the physiologic response is to increase the respiratory rate and tidal volume to blow off the excess CO2. Vomiting and increased urination may occur with hyperglycemia, but not as physiologic responses to metabolic acidosis. The heart rate will increase.

Question 10 of 21 A patient with recurrent shortness of breath has just had a bronchoscopy. What is a priority nursing action immediately after the procedure? A. Monitor the patient for laryngeal edema. B. Assess the patient's level of consciousness. C. Monitor and manage the patient's level of pain. D. Assess the patient's heart rate and blood pressure.

ANS: Monitor the patient for laryngeal edema. Priorities for assessment are the patient's airway and breathing, both of which may be compromised after bronchoscopy by laryngeal edema. These assessment parameters supersede the importance of loss of consciousness (LOC), pain, heart rate, and blood pressure, although the nurse should also be assessing these

Question 17 of 21 After assisting at the bedside with a thoracentesis, the nurse should continue to assess the patient for signs and symptoms of what? A. Bronchospams B. Pneumothorac C. Pulmonary edema D. Respiratory acidosis

ANS: Pneumothorax Because thoracentesis involves the introduction of a catheter into the pleural space, there is a risk of pneumothorax. Thoracentesis does not carry a significant potential for causing bronchospasm, pulmonary edema, or respiratory acidosis.

Question 21 of 21 A patient with a recent history of a dry cough has had a chest x-ray that revealed the presence of nodules. In an effort to determine whether the nodules are malignant or benign, what is the primary care provider likely to order? A. Thoracentesis B. Pulmonary angiogram C. CT scan of the patient's chest D. Positron emission tomography (PET)

ANS: Positron emission tomography (PET) PET is used to distinguish benign and malignant pulmonary nodules. Because malignant lung cells have an increased uptake of glucose, the PET scan (which uses an IV radioactive glucose preparation) can demonstrate increased uptake of glucose in malignant lung cells. This differentiation cannot be made using CT, a pulmonary angiogram, or thoracentesis. END OF BONUS ELSEVIER QUESTIONS

Question 9 of 21 The patient's arterial blood gas results show the PaO2 at 65 mmHg and SaO2 at 80%. What early manifestations should the nurse expect to observe in this patient? A. Restlessness, tachypnea, tachycardia, and diaphoresis B. Unexplained confusion, dyspnea at rest, hypotension, and diaphoresis C. Combativeness, retractions with breathing, cyanosis, and decreased output D. Coma, accessory muscle use, cool and clammy skin, and unexplained fatigue

ANS: Restlessness, tachypnea, tachycardia, and diaphoresis With inadequate oxygenation, early manifestations include restlessness, tachypnea, tachycardia, and diaphoresis, decreased urinary output, and unexplained fatigue. The unexplained confusion, dyspnea at rest, hypotension, and diaphoresis; combativeness, retractions with breathing, cyanosis, and decreased urinary output; coma, accessory muscle use, cool and clammy skin, and unexplained fatigue occur as later manifestations of inadequate oxygenation.

Question 20 of 21 During the assessment in the emergency department, the nurse is palpating the patient's chest. Which finding is a medical emergency? A. Increase tactile fremitus B. Diminished chest movement C. Tracheal deviation to the left D. Decreased anteroposterior (AP) diameter.

ANS: Tracheal deviation to the left Tracheal deviation is a medical emergency when it is caused by a tension pneumothorax. Tactile fremitus increases with pneumonia or pulmonary edema and decreases in pleural effusion or lung hyperinflation. Diminished chest movement occurs with barrel chest, restrictive disease, and neuromuscular disease.

Question 7 of 21 The nurse is caring for a patient who had abdominal surgery yesterday. Today the patient's lung sounds in the lower lobes are diminished. The nurse knows this could be related to the occurrence of A. Pain B. Atelectasis C. Pneumonia D. Pleural effusion

ANS: atelectasis. Postoperatively, there is an increased risk for atelectasis from anesthesia as well as restricted breathing from pain. Without deep breathing to stretch the alveoli, surfactant secretion to hold the alveoli open is not promoted. Pneumonia will occur later after surgery. Pleural effusion occurs because of blockage of lymphatic drainage or an imbalance between intravascular and oncotic fluid pressures, which is not expected in this case.

LEWIS End of Chapter Questions: Assessment of Respiratory System: 1. To promote the release of surfactant, the nurse encourages the patient to: a. take deep breaths. b. cough five times per hour to prevent alveolar collapse. c. decrease fluid intake to reduce fluid accumulation in the alveoli d. sit with head of bed elevated to promte air movement through the pores of Kohn

Correct answer: a Rationale: Surfactant is a lipoprotein that lowers the surface tension in the alveoli. It reduces the amount of pressure needed to inflate the alveoli and decreases the tendency of the alveoli to collapse. Deep breaths stretch the alveoli and promote surfactant secretion.

Question 13 of 21 A 67-yr-old male patient had a right total knee replacement 2 days ago. Upon auscultation of the patient's posterior chest, the nurse detects discontinuous, high-pitched breath sounds just before the end of inspiration in the lower portion of both lungs. Which statement most appropriately reflects how the nurse should document the breath sounds? A. "Bibasilar wheezes present on inspiration." B. "Diminished breath sounds in the bases of both lungs." C. "Fine crackles posterior right and left lower lung fields." D. "Expiratory wheezing scattered throughout the lung fields."

Fine crackles are described as a series of short-duration, discontinuous, high-pitched sounds heard just before the end of inspiration.