Chapter 26

A patient with a chronic cough has a bronchoscopy. Which action will be included in the nursing care plan after the procedure?

Keep the patient NPO until the gag reflex returns. 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.

A patient is admitted with a metabolic acidosis of unknown origin. Based on this diagnosis, the nurse would expect the patient to have

Kussmaul respirations. Kussmaul (deep and rapid) respirations are a compensatory mechanism for metabolic acidosis.

After the nurse has received change-of-shift report, which of these patients should be assessed first?

A patient with possible lung cancer who has just returned after bronchoscopy Since the cough and gag are decreased after bronchoscopy, this patient should be assessed for airway maintenance.

The nurse palpates the posterior chest while the patient says "99" and notes that no vibration is felt. How should this be charted?

Absent tactile fremitus 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."

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?

Administer the PRN supplemental O2. The drop in SpO2 to 85% indicates that the patient is hypoxemic and needs supplemental oxygen when exercising.

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?

Arrange for the patient's spouse to be present during the teaching. Hypoxemia interferes with the patient's ability to learn and retain information, so having the patient's spouse present will increase the likelihood that discharge instructions will be followed.

When assessing the respiratory system of a 78-year-old patient, which finding indicates that the nurse should take immediate action?

Crackles are heard from the lung bases to the midline. Crackles in the lower half of the lungs indicate that the patient may have an acute problem such as heart failure.

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?

Perform a respiratory system assessment and ask specific questions about this episode of respiratory distress. 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.

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?

Place the patient on high-flow oxygen. 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 until the patient is normothermic.

Which nursing actions will be included when sending a patient for computed tomography (CT) of the chest with contrast

Question the patient about allergies to iodine. Review the recent blood urea nitrogen (BUN) and creatinine levels. Since the contrast dye is iodine-based and may cause dehydration and decreased renal blood flow, asking about iodine allergies and monitoring renal function before the CT scan is necessary.

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?

Respirations are 36 breaths/minute. The increase in respiratory rate indicates respiratory distress and a need for rapid interventions such as administration of oxygen or medications.

When preparing the patient with a right-sided pleural effusion for a thoracentesis, how will the nurse position the patient?

Sitting upright with the arms supported on an over bed table 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.

Which action will the nurse plan to take for a patient who is scheduled for pulmonary function testing (PFT)?

Teach deep inhalation and forceful exhalation. For PFT, the patient should inhale deeply and exhale as long, hard, and fast as possible.

When the nurse is analyzing the results of a patient's arterial blood gases (ABGs), which finding indicates the need for most immediate action?

The partial pressure of oxygen in arterial blood (PaO2) is 59 mm Hg. 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 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?

The patient has been using the albuterol (Proventil) inhaler more frequently over the last 4 days. 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.

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?

The patient is allergic to shellfish. Because the contrast solution used during a spiral CT is iodine-based, the patient may need to have the CT scan without contrast or be premedicated before contrast injection.

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?

The student places the stethoscope over the scapulae and then auscultates. The stethoscope should be placed over lung tissue, not over bony structures.

When auscultating a patient's chest while the patient takes a deep breath, the nurse hears loud, high-pitched, "blowing" sounds at both lung bases. The nurse will document these as

abnormal sounds. The description indicates that the nurse hears bronchial breath sounds that are abnormal when heard at the lung base.

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

expiratory wheezes in both lungs. Wheezes are high-pitched sounds. In this case they are heard during the expiratory phase of the respiratory cycle.

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?

pH 7.31, PaO2 91 mm Hg, PaCO2 50 mm Hg, and O2 sat 96% These ABGs indicate uncompensated respiratory acidosis and should be reported to the health care provider.

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

spiral computed tomography (CT) scan. Spiral CT scans are the most commonly used test to diagnose pulmonary emboli.