RESPIRATORY SYSTEM (Elsevier)- QUIZ 2

Which questions should the nurse ask when assessing a patient's sleep/rest pattern related to respiratory health? Select all that apply.

1. "Do you have trouble falling asleep." 3. "Do you awaken abruptly during the night?" 5. "Do you need to sleep with the head elevated?" RATIONALE: The patient with sleep apnea may have insomnia or abrupt awakenings. 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 eight hours per night or needing to urinate during the night is not indicative of impaired respiratory health. p. 461

In which order will the nurse place the stethoscope on the anterior chest to auscultate breath sounds?

1. Above the clavicles 2. Below the clavicles 3. Above the nipple line 4. At the nipple line 5. Below the nipple line RATIONALE: The nurse would auscultate the anterior chest on bilateral locations, starting at the apices of the lungs above the clavicles. The stethoscope would then be moved below the clavicles for auscultation. The nurse would continue to move down the chest, placing the stethoscope above the nipple line, then at the nipple line, and finally below the nipple line.

Which conditions may cause a false-negative reaction in a tuberculin test? Select all that apply.

1. Anergy/Immunosuppression 3. Overwhelming Tuberculosis (TB) Infection 4. TB infection within 8 to 10 weeks of exposure RATIONALE: False-negative reactions may occur in people who have anergy or are immunosuppressed, those who had a TB infection within 8 to 10 weeks of exposure, those with overwhelming TB infection, and patients who had a recent live virus vaccination, such as one for measles or chickenpox. Positive reactions are more likely to occur in IVDA patients and in patients who had recent contact with a person who had TB. Recent antibiotic therapy for MRSA has no direct effect on tuberculin test results. p. 471

In which order will the nurse hear these sounds from percussion of the anterior chest over the clavicle, then the lung field, then the liver, and finally over the stomach?

1. Flatness 2. Resonance 3. Dullness 4. Tympany RATIONALE: The nurse would hear flatness with percussion over the clavicle, followed by resonance over the lung field. Dullness would be heard over the liver, and then Tympany with percussion over the stomach.

Which sputum characteristics, if present in the patient, may need further evaluation for a patient who is a smoker and has chronic obstructive pulmonary disease (COPD)? Select all that apply.

1. Frothy 2. Foul Odor 3. Pink Tinged RANTIONALE: COPD may result in whitish to yellowish sputum; however, any change in the baseline characteristics of the sputum should be reported. Frothy sputum may indicate pulmonary edema and needs further evaluation. A foul odor in the sputum indicates presence of infection and needs immediate medical intervention. Pink-tinged sputum may indicate pulmonary edema and the patient may need further evaluation. Sputum with brown specks is a common finding in a person who smokes. Yellowish sputum is a normal finding in COPD. p. 462

Which information does the nurse need to obtain and document in the admission assessment on a patient who uses oxygen (O2) at home? Select all that apply.

1. Liter Flow 2. Home Safety Practices 5. Method and Effectiveness of Administration 6. Fractional Inspired Oxygen Concentration (FIo2) RATIONALE: If the patient is using O2 for a breathing problem, record the FIO2, flow rate (liters per minute), method of administration, number of hours used per day, and effectiveness of the therapy. Assess safety practices, including the patient's cognitive and physical ability related to using O2 and any metered-dose inhalers. What oxygen service the patient uses and the patient's method of payment are not necessary to determine in the admission assessment. p. 460

Which disease processes are associated with a pleural friction rub? Select all that apply.

1. Pneumonia 5. Pulmonary Infarction RATIONALE: Pleural friction, characterized by a creaking or grating sound during inspiration or expiration, is caused by roughened, inflamed pleural surfaces rubbing together. Pneumonia and pulmonary infarction can lead to pleural friction. Cystic fibrosis causes continuous rumbling, snoring, or rattling sounds when rhonchi obstruct large airways. Wheezes are present in the patient with bronchospasm. Pulmonary edema is associated with coarse crackles caused by air passing through the airway when it is intermittently occluded by mucus. p.467

Which cognitive changes are characteristic of a patient experiencing hypoxia? Select all that apply.

1. Restlessness 2. Apprehension 4. Memory Changes RATIONALE: A patient who is hypoxic may have neurologic symptoms that include apprehension, restlessness, irritability, and memory changes. Mood will worsen rather than improve. Pursed lip breathing is not a cognitive symptom. Concentration will be poor with hypoxia rather than improved. p. 463

Which factors may cause the pulse oximeter to have an inaccurate reading in an African patient who was rescued from a fire? Select all that apply.

1. The patient had darker skin 2. The patient has Methemoglobinemia 3. The patient has an Hgb level of 8.0 mg/ml RATIONALE: Pulse oximetry helps to measure arterial oxygen saturation (SpO2) through a probe, which can be placed on the finger, toe, ear, or bridge of the nose. SpO2 readings may be inaccurate in a patient with dark skin because the skin color can interfere with transmission of signals from the pulse oximeter to the body tissues. Methemoglobinemia can occur as a result of breathing gases during fire accidents. This form of hemoglobin has less capacity for carrying oxygen and may interfere with the results of the oximeter. An Hgb level of 8.0 mg/dL indicates anemia, which may interfere with the results of pulse oximetry because there would be lower levels of the hemoglobin protein to carry oxygen. Soft, pink fingernails are a normal finding in patients, regardless of skin tone, and should not interfere with the SpO2 results. Nails with thick acrylic fingernail polish, however, may not yield accurate results. Blood sugar levels do not interfere with SpO2 results. p. 466

An older adult may present with which respiratory assessment findings? Select all that apply.

1. Thicker Mucus 3. Decreased Chest Wall Movement 5. Diminished Breath Sounds, particularly at lung bases RATIONALE: Changes in the respiratory system in the older adult include thickened mucus, decreased chest wall movement, and diminished breath sounds, especially at the lung bases. The PaO2 and SaO2 levels are decreased. p.460

Which questions will the nurse ask when assessing the effects of a patient's respiratory diagnosis on activity-exercise patterns? Select all that apply.

2. "Do you have trouble walking due to shortness of breath?" 4. "How many flights of stairs can you walk up before you are short of breath?" RATIONALE: When assessing the effects that a respiratory diagnosis has on activity-exercise patterns, the nurse will ask the patient if walking is impacted by dyspnea and how many flights of steps the patient can walk up before dyspnea occurs. Asking the patient about urinary incontinence with coughing is appropriate when assessing elimination patterns. Asking the patient if the spouse wakes him or her up in the middle of the night due to snoring will assess sleep-rest patterns. Asking the patient if he or she feels full quickly when eating assesses the patient's nutritional-metabolic pattern. p. 46

Which patient findings indicate inadequate oxygenation? Select all that apply.

2. Cyanosis 3. Tachypnea 4. Diaphoresis RATIONALE: The symptoms of inadequate oxygenation in the patient include cyanosis, diaphoresis, and tachypnea. Cyanosis indicates inadequate perfusion due to compromised oxygenation. Diaphoresis and tachypnea occur due to sympathetic stimulation to compensate for inadequate oxygenation. Anemia occurs gradually and does not suddenly cause inadequate oxygenation. Hypertension does not indicate inadequate oxygenation in the patient. p. 458

The nurse would expect which assessment findings in a patient with late manifestations of inadequate oxygenation? Select all that apply.

2. Use of Accessory Muscles 4. Cyanosis and cool, clammy skin 5. Pausing for a breath between sentences and words RATIONALE: Late manifestations of inadequate oxygenation include use of accessory muscles; cyanosis and cool, clammy skin; and pausing for breath between sentences and words. Mild hypertension, apprehension, and restlessness are early manifestations of inadequate oxygenation. p.456

The nurse expects to note which type of fremitus in a patient with a pneumothorax?

Absent RATIONALE: In a patient with pneumothorax, the nurse would find absent fremitus. Increased fremitus is found in pneumonia, in lung tumors, with thick bronchial secretions, and above a pleural effusion. As the patient's voice moves through a dense tissue or fluid-filled lungs, the vibration is increased. Decreased fremitus may be found in pleural effusion when the hand is farther from the lung, and in barrel chest where the lung is hyperinflated. p. 465

Which term is used to describe abnormal breath sounds?

Adventitious RATIONALE: Adventitious is the term used to describe abnormal breath sounds such as crackles, rhonchi, wheezes, and a pleural friction rub. The three normal breath sounds are vesicular, bronchovesicular, and bronchial sounds. Vesicular sounds are relatively soft, low-pitched, gentle, rustling sounds. Bronchial sounds are louder and higher pitched; they resemble air blowing through a hollow pipe. Bronchovesicular sounds have a medium pitch and intensity and are heard anteriorly over the main stem bronchi on either side of the sternum and posteriorly between the scapulae. p. 467

The nurse expects which test will be prescribed for a patient following a transthoracic needle aspiration (TTNA)?

Chest X-Ray RATIONALE: A percutaneous or TTNA biopsy involves inserting a needle through the chest wall, usually under bedside ultrasound or CT guidance. Because of the risk for a pneumothorax, a chest x-ray is done after TTNA to check for air in the pleura. A chest x-ray is sufficient to diagnose pneumothorax, so a lung biopsy, MRI, or CT of lungs is not required. p. 478

Which condition would the nurse associate with decreased breath sounds in a patient who is postoperative day one following abdominal surgery?

Atelectasis RATIONALE: Following abdominal surgery, the patient is at risk for atelectasis related to the effects of anesthesia as well as restricted breathing from pain. This condition is associated with a decrease in breath sounds on auscultation. Without deep breathing to stretch the alveoli, surfactant secretion to hold the alveoli open is not promoted. Pneumonia is a risk several days after surgery but is not typical on postoperative day one. Pneumothorax is associated with absent breath sounds. 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. p. 468

Which condition is associated with tachypnea and clubbing of the fingers?

Chronic Hypoxemia RATIONALE: Tachypnea and clubbing of the fingers support the diagnosis of chronic hypoxemia. Pursed-lip breathing, inability to lie in a flat position, and use of accessory muscles to assist with breathing are findings observed in patients with asthma and chronic obstructive pulmonary disease. Voluntary decrease in tidal volume to reduce pain on chest expansion is referred to as splinting, which is a common manifestation of chest trauma or pleurisy. p. 468

Which diagnosis does the nurse expect based on the following respiratory assessment findings?

Chronic Obstructive Pulmonary Disease (COPD) INSPECTION: Barrel chest, pursed-lip breathing PALPATION: Diminished Excursion PERCUSSION: Hyperresonance AUSCULTATION: Distant crackles and wheezing RATIONALE: These assessment findings indicate COPD. With pneumonia, pleural effusion, and pulmonary edema, percussion would be dull over the affected areas, not hyperresonant.

Which condition is associated with wheezing?

Chronic Obstructive Pulmonary Disease (COPD) RATIONALE: Wheezes are continuous high-pitched squeaking sounds produced by the rapid vibration of the bronchial walls. The rapid vibration is caused by a blockage in the airways, which often occurs with chronic obstructive pulmonary disease. Fine crackles are heard with atelectasis. Diminished breath sounds are heard in pleural effusion. Fine or coarse crackles are heard in patients with pulmonary edema. p. 468

A patient diagnosed with asthma who is experiencing airway irritation may present with which assessment finding?

Dry, hacking cough RATIONALE: A dry, hacking cough indicates the patient is experiencing airway irritation or obstruction. Hemoptysis often occurs with tuberculosis and does not indicate airway irritation. A harsh, barky cough suggests upper airway obstruction. A loose-sounding cough indicates secretions. p. 462

Why might a patient with lung cancer develop a pleural effusion?

Lymphatic drainage blocked by malignant cells RATIONALE: The most common cause for the development of pleural effusion in the patient suffering from malignancy is lymphatic drainage blocked by malignant cells. An allergic reaction may not lead to pleural effusion. Bacterial infection is unlikely in the absence of other signs. Malignancy is not the cause of raised BP. p. 469

The nurse would expect which assessment finding in a patient with pulmonary fibrosis?

Normal Percussion RATIONALE: Patients with pulmonary fibrosis have normal percussion findings. Inspection would reveal tachypnea, and palpation would show movement. Auscultation shows crackles or sounds like Velcro being pulled apart. Prolonged expiration occurs with asthma. Egophony over effusion often occurs with pleural effusion. Fremitus over the affected area occurs with pneumonia. p. 469

Which diagnostic study is used to distinguish benign and cancerous lung nodules?

Positron Emission Tomography (PET) RATIONALE: 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 a thoracentesis, pulmonary angiogram, or CT. p. 472

Which diagnosis will the nurse anticipate for a patient who presents with dyspnea, bluish discoloration of the lips, fine crackles on auscultation, and dullness upon percussion of the lung fields?

Pulmonary Edema RATIONALE: Dyspnea, cyanosis, fine crackles, and dullness on percussion all support the diagnosis of pulmonary edema. Wheezing and hyperresonance on percussion support the diagnosis of asthma. Tachypnea, diminished or absent breath sounds, and dullness on percussion support the diagnosis of pleural effusion. Tachypnea, crackles, and resonance on percussion support the diagnosis of pulmonary fibrosis.. p. 469

Which early manifestations of distress will the nurse expect in a patient whose arterial blood gas results show the partial pressure of oxygen (PaO2) at 65 mm Hg and the arterial oxygen saturation (SaO2) at 80%?

Restlessness, Tachycardia, and Diaphoresis RATIONALE: With inadequate oxygenation, early manifestations include restlessness, tachypnea, tachycardia, diaphoresis, decreased urinary output, and unexplained fatigue. The unexplained confusion, dyspnea at rest, hypotension, diaphoresis, combativeness, retractions with breathing, cyanosis, decreased urinary output, coma, accessory muscle use, cool and clammy skin, and unexplained fatigue occur as later manifestations of inadequate oxygenation. p. 470

A positron emission tomography (PET) scan is used for which respiratory assessment?

To distinguish benign and malignant nodules RATIONALE: PET scans use an IV radioactive glucose preparation to demonstrate increased uptake of glucose in malignant lung cells. A ventilation/perfusion (VQ) scan is used to assess ventilation and perfusion of lungs. A pulmonary angiogram is used to visualize pulmonary vasculature and locate obstruction. An MRI test is used to diagnose lesions difficult to assess by CT scan. p. 472

Which chest palpation finding is a medical emergency?

Trachea moved to the left RATIONALE: 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. p. 468

Which chest palpation finding is a medical emergency?

Trachea moved to the left RATIONALE: 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. p. 468

Which test will be conducted to confirm the diagnosis of tuberculosis (TB) for a patient experiencing a chronic cough?

Tuberculin Test RATIONALE: The nurse recommends the tuberculin skin test to check for TB. A lepromin test is done to check for leprosy. A Widal test is useful for diagnosing typhoid infection. A Benedict's test is performed to check urine glucose. p. 471