ch 20 prepU
The nurse is caring for a patient diagnosed with pneumonia. The nurse will assess the patient for tactile fremitus by completing which of the following? a) Asking the patient to repeat "ninety-nine" as the nurse's hands move down the patient's thorax b) Placing the thumbs along the costal margin of the chest wall and instructing the patient to inhale deeply c) Asking the patient to say "one, two, three" while auscultating the lungs d) Instructing the patient to take a deep breath and hold it while the diaphragm is percussed
a. Asking the patient to repeat "ninety-nine" as the nurse's hands move down the patient's thorax Explanation: While the nurse is assessing for tactile fremitus, the patient is asked to repeat "ninety-nine" or "one, two, three," or "eee, eee, eee" as the nurse's hands move down the patient's thorax. The vibrations are detected with the palmar surfaces of the fingers and hands, or the ulnar aspect of the extended hands, on the thorax. The hand or hands are moved in sequence down the thorax. Corresponding areas of the thorax are compared. Asking the patient to say "one, two, three" while auscultating the lungs is not the proper technique for assessing for tactile fremitus. The nurse assesses for anterior respiratory excursion by placing the thumbs along the costal margin of the chest wall and instructing the patient to inhale deeply. The nurse assesses for diaphragmatic excursion by instructing the patient to take a deep breath and hold it while the diaphragm is percussed.
Which of the following is a late sign of hypoxia? a) Cyanosis b) Restlessness c) Somnolence d) Hypotension
a. Cyanosis Explanation: Cyanosis is a late sign of hypoxia. Hypoxia may cause restlessness and an initial rise in blood pressure that is followed by hypotension and somnolence.
The nurse enters the room of a client who is being monitored with pulse oximetry. Which of the following factors may alter the oximetry results? a) Diagnosis of peripheral vascular disease b) Increased temperature of the room c) Reduced lighting in the room d) Placement of the probe on an earlobe
a. Diagnosis of peripheral vascular disease Explanation: Pulse oximetry is a noninvasive method of monitoring oxygen saturation of hemoglobin. A probe is placed on the fingertip, forehead, earlobe, or bridge of nose. Inaccuracy of results may be from anemia, bright lights, shivering, nail polish, or peripheral vascular disease.
A physician has ordered that a client with suspected lung cancer undergo magnetic resonance imaging (MRI). The nurse explains the benefits of this study to the client. Included in teaching would be which of the following regarding the MRI? a) MRI can view soft tissues and can help stage cancers. b) Lung blood flow can be viewed after a radiopaque agent is injected. c) Tumor densities can be seen with radiolucent images. d) Narrow-beam x-ray can scan successive lung layers.
a. MRI can view soft tissues and can help stage cancers. Explanation: MRI uses magnetic fields and radiofrequency signals to produce a detailed diagnostic image. MRI can visualize soft tissues, characterize nodules, and help stage carcinomas. The other options describe different studies
The nurse is caring for a patient who is to undergo a thoracentesis. In preparation for the procedure, the nurse will position the patient in which of the following positions? a) Sitting on the edge of the bed b) Supine c) Prone d) Lateral recumbent
a. Sitting on the edge of the bed Explanation: If possible, it is best to place the patient upright or sitting on the edge of the bed with the feet supported and arms and head on a padded over-the-bed table. Other positions in which the patient could be placed include straddling a chair with arms and head resting on the back of the chair, or lying on the unaffected side with the head of the bed elevated 30 to 45 degrees if unable to assume a sitting position.
A client with a suspected pulmonary disorder undergoes pulmonary function tests. To interpret test results accurately, the nurse must be familiar with the terminology used to describe pulmonary functions. Which term refers to the volume of air inhaled or exhaled during each respiratory cycle? a) Tidal volume b) Vital capacity c) Functional residual capacity d) Maximal voluntary ventilation
a. Tidal volume Explanation: Tidal volume refers to the volume of air inhaled or exhaled during each respiratory cycle when breathing normally. Normal tidal volume ranges from 400 to 700 ml. Vital capacity refers to the total volume of air that can be exhaled during a slow, maximal expiration after maximal inspiration. Functional residual capacity refers to the volume of air remaining in the lungs after a normal expiration. Maximal voluntary ventilation is the greatest volume of air expired in 1 minute with maximal voluntary effort.
The nurse is caring for a patient with recurrent hemoptysis who has undergone a bronchoscopy. Immediately following the procedure, the nurse should complete which of the following? a) Instruct the patient that bed rest must be maintained for 2 hours. b) Assess the patient for a cough reflex. c) Ensure the patient remains moderately sedated to decrease anxiety. d) Offer the patient ice chips.
b. Assess the patient for a cough reflex. Explanation: After the procedure, the patient must take nothing by mouth until the cough reflex returns, because the preoperative sedation and local anesthesia impair the protective laryngeal reflex and swallowing. Once the patient demonstrates a cough reflex, the nurse may offer ice chips and eventually fluids. The patient is sedated during the procedure, not afterward. The patient is not required to maintain bed rest following the procedure.
Which of the following clinical manifestations should a nurse monitor for during a pulmonary angiography, which indicates an allergic reaction to the contrast medium? a) Urge to cough b) Difficulty in breathing c) Absent distal pulses d) Hematoma
b. Difficulty in breathing Explanation: Nurses must determine if the client has any allergies, particularly to iodine, shellfish, or contrast dye. During the procedure, the nurse should check for signs and symptoms of allergic reactions to the contrast medium, such as itching, hives, or difficulty in breathing. The nurses inspects for hematoma, absent distal pulses, after the procedure. When the contrast medium is infused, an urge to cough is often a sensation experienced by the client.
A nurse is concerned that a client may develop postoperative atelectasis. Which nursing diagnosis would be most appropriate if this complication occurs? a) Decreased cardiac output b) Impaired gas exchange c) Impaired spontaneous ventilation d) Ineffective airway clearance
b. Impaired gas exchange Explanation: Airflow is decreased with atelectasis, which is a bronchial obstruction from collapsed lung tissue. If there is an obstruction, there is limited or no gas exchange in this area. Impaired gas exchange is thus the most likely nursing diagnosis with atelectasis.
When assessing a client, which adaptation indicates the presence of respiratory distress? a) Sore throat b) Orthopnea c) Productive cough d) Respiratory rate of 14 breaths per minute
b. Orthopnea Explanation: Orthopnea is the inability to breathe easily except when upright. This positioning can mean while in bed and propped with a pillow or sitting in a chair. If a client cannot breathe easily while lying down, there is an element of respiratory distress.
A nurse assesses a client's respiratory status. Which observation indicates that the client is having difficulty breathing? a) Pursed-lip breathing b) Use of accessory muscles c) Controlled breathing d) Diaphragmatic breathing
b. Use of accessory muscles Explanation: The use of accessory muscles for respiration indicates the client is having difficulty breathing. Diaphragmatic and pursed-lip breathing are two controlled breathing techniques that help the client conserve energy
If concern exists about fluid accumulation in a client's lungs, what area of the lungs will the nurse focus on during assessment? a) Left lower lobe b) Posterior bronchioles c) Bilateral lower lobes d) Anterior bronchioles
c. Bilateral lower lobes Explanation: Crackles are secondary to fluid in the alveoli and create a soft, discontinuous popping sound. Because fluid creates these adventitious sounds, the principle of gravity will remind the nurse to focus the assessment on the lower portion of the thorax or the lower lobes of the lungs.
The nurse is assessing the lungs of a patient diagnosed with pulmonary edema. Which of the following would be expected upon auscultation? a) Bronchial breath sounds b) Egophony c) Crackles at lung bases d) Absent breath sounds
c. Crackles at lung bases Explanation: A patient with pulmonary edema would be expected to have crackles in the lung bases, and possible wheezes. Egophony may occur in patients diagnosed with pleural effusion. Absent breath sounds occurs in pneumothorax. Bronchial breath sounds occur in consolidation, such as pneumonia
A client has a nursing diagnosis of "ineffective airway clearance" as a result of excessive secretions. An appropriate outcome for this client would be which of the following? a) Client reports no chest pain. b) Respiratory rate is 12 to 18 breaths per minute. c) Lungs are clear on auscultation. d) Client can perform incentive spirometry.
c. Lungs are clear on auscultation. Explanation: Assessment of lung sounds includes auscultation for airflow through the bronchial tree. The nurse evaluates for fluid or solid obstruction in the lung. When airflow is decreased, as with fluid or secretions, adventitious sounds may be auscultated. Often crackles are heard with fluid in the airways.
A nurse is reviewing arterial blood gas results on an assigned client. The pH is 7.32 with PCO2 of 49 mm Hg and a HCO3−of 28 mEq/L. The nurse reports to the physician which finding? a) Metabolic alkalosis b) Metabolic acidosis c) Respiratory acidosis d) Respiratory alkalosis
c. Respiratory acidosis Explanation: Respiratory acidosis would be reported to the physician citing the lab values. Analysis of the blood gases reveals that the client is acidotic with a pH under 7.35. Also noted is the PCO2above the normal range of 30 to 40 mm Hg. The HCO3− is slightly elevated because the normal level is 22 to 26 mEq/L.
The nurse is admitting a client who just had a bronchoscopy. Which assessment should be the nurse's priority? a) Presence of carotid pulse b) Medication allergies c) Swallow reflex d) Ability to deep breathe
c. Swallow reflex Explanation: The physician sprays a local anesthetic into the client's throat before performing a bronchoscopy. The nurse must assess the swallow reflex when the client returns to the unit and before giving him anything by mouth. The nurse should also assess for medication allergies, carotid pulse, and deep breathing, but they aren't the priority at this time.
The nurse working in the radiology clinic is assisting with a pulmonary angiography. The nurse knows that when monitoring clients after a pulmonary angiography, what should the physician be notified about? a) Excessive capillary refill b) Flushed feeling in the client c) Raised temperature in the affected limb d) Absent distal pulses
d. Absent distal pulses Explanation: When monitoring clients after a pulmonary angiography, nurses must notify the physician about diminished or absent distal pulses, cool skin temperature in the affected limb, and poor capillary refill. When the contrast medium is infused, the client will sense a warm, flushed feeling.
A client is receiving moderate sedation while undergoing bronchoscopy. Which assessment finding should the nurse attend to immediately? a) Absent cough and gag reflexes b) Respiratory rate of 13 breaths/min c) Blood-tinged secretions d) Oxygen saturation of 90%
d. Oxygen saturation of 90% Explanation: The nurse should respond immediately to an oxygen saturation (SaO2) of 90%. Normal SaO2 ranges from 95% to 100%. Therefore, an SaO2 of 90% indicates inadequate oxygenation, an adverse effect of moderate sedation. The nurse should respond by attempting to arouse the client, assisting the client with deep breathing, and administering a higher dose of oxygen. Cough and gag reflexes are typically absent after administration of anesthetics required for bronchoscopy, and they usually return about 2 hours after the procedure. Blood-tinged secretions are common for several hours after bronchoscopy, especially if a biopsy was obtained. A respiratory rate of 13 breaths/minute is within normal limits.
