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he nurse is caring for a patient who has returned to the unit following a bronchoscopy. The patient is asking for something to drink. Which criterion will determine when the nurse should allow the patient to drink fluids? A)presence of a cough and gag reflex B)Absence of nausea C)Ability to demonstrate deep inspiration D)Oxygen saturation of ³92%
A Feedback: After the procedure, it is important that the patient takes nothing by mouth until the cough reflex returns because the preoperative sedation and local anesthesia impair the protective laryngeal reflex and swallowing for several hours. Deep inspiration, adequate oxygen saturation levels, and absence of nausea do not indicate that oral intake is safe from the risk of aspiration.
The nurse has assessed a patient's family history for three generations. The presence of which respiratory disease would justify this type of assessment? A)Asthma B)Obstructive sleep apnea C)Community-acquired pneumonia D)Pulmonary edema
A Feedback: Asthma is a respiratory illness that has genetic factors. Sleep apnea, pneumonia, and pulmonary edema lack genetic risk factors.
A patient on the medical unit has told the nurse that he is experiencing significant dyspnea, despite that he has not recently performed any physical activity. What assessment question should the nurse ask the patient while preparing to perform a physical assessment? A)On a scale from 1 to 10, how bad would rate your shortness of breath? B)When was the last time you ate or drank anything? C)Are you feeling any nausea along with your shortness of breath? D)Do you think that some medication might help you catch your breath?
A Feedback: Gauging the severity of the patient's dyspnea is an important part of the nursing process. Oral intake and nausea are much less important considerations. The nurse must perform assessment prior to interventions such as providing medication.
The medical nurse who works on a pulmonology unit is aware that several respiratory conditions can affect lung tissue compliance. The presence of what condition would lead to an increase in lung compliance? A)Emphysema B)Pulmonary fibrosis C)Pleural effusion D)Acute respiratory distress syndrome (ARDS)
A Feedback: High or increased compliance occurs if the lungs have lost their elasticity and the thorax is overdistended, in conditions such as emphysema. Conditions associated with decreased compliance include pneumothorax, hemothorax, pleural effusion, pulmonary edema, atelectasis, pulmonary fibrosis, and ARDS.
The nurse is performing a respiratory assessment of an adult patient and is attempting to distinguish between vesicular, bronchovesicular, and bronchial (tubular) breath sounds. The nurse should distinguish between these normal breath sounds on what basis? A)Their location over a specific area of the lung B)The volume of the sounds C)Whether they are heard on inspiration or expiration D)Whether or not they are continuous breath sounds
A Feedback: Normal breath sounds are distinguished by their location over a specific area of the lung; they are identified as vesicular, bronchovesicular, and bronchial (tubular) breath sounds. Normal breath sounds are heard on both inspiration and expiration, and are continuous. They are not distinguished solely on the basis of volume.
The clinic nurse is caring for a patient who has been diagnosed with emphysema and who has just had a pulmonary function test (PFT) ordered. The patient asks, What exactly is this test for? What would be the nurse's best response? A)A PFT measures how much air moves in and out of your lungs when you breathe. B)A PFT measures how much energy you get from the oxygen you breathe. C)A PFT measures how elastic your lungs are. D)A PFT measures whether oxygen and carbon dioxide move between your lungs and your blood.
A Feedback: PFTs are routinely used in patients with chronic respiratory disorders. They are performed to assess respiratory function and to determine the extent of dysfunction. Such tests include measurements of lung volumes, ventilatory function, and the mechanics of breathing, diffusion, and gas exchange. Lung elasticity and diffusion can often be implied from PFTs, but they are not directly assessed. Energy obtained from respiration is not measured directly.
The nurse is caring for a patient with a lower respiratory tract infection. When planning a focused respiratory assessment, the nurse should know that this type of infection most often causes what? A)Impaired gas exchange B)Collapsed bronchial structures C)Necrosis of the alveoli D)Closed bronchial tree
A Feedback: The lower respiratory tract consists of the lungs, which contain the bronchial and alveolar structures needed for gas exchange. A lower respiratory tract infection does not collapse bronchial structures or close the bronchial tree. An infection does not cause necrosis of lung tissues.
The ED nurse is assessing a patient complaining of dyspnea. The nurse auscultates the patient's chest and hears wheezing throughout the lung fields. What might this indicate? A)The patient has a narrowed airway. B)The patient has pneumonia. C)The patient needs physiotherapy. D)The patient has a hemothorax.
A Feedback: Wheezing is a high-pitched, musical sound that is often the major finding in a patient with bronchoconstriction or airway narrowing. Wheezing is not normally indicative of pneumonia or hemothorax. Wheezing does not indicate the need for physiotherapy.
A nurse educator is reviewing the implications of the oxyhemoglobin dissociation curve with regard to the case of a current patient. The patient currently has normal hemoglobin levels, but significantly decreased SaO2 and PaO2 levels. What is an implication of this physiological state? A)The patient's tissue demands may be met, but she will be unable to respond to physiological stressors. B)The patient's short-term oxygen needs will be met, but she will be unable to expel sufficient CO2. C)The patient will experience tissue hypoxia with no sensation of shortness of breath or labored breathing. D)The patient will experience respiratory alkalosis with no ability to compensate.
A Feedback: With a normal hemoglobin level of 15 mg/dL and a PaO2 level of 40 mm Hg (SaO2 75%), there is adequate oxygen available for the tissues, but no reserve for physiological stresses that increase tissue oxygen demand. If a serious incident occurs (e.g., bronchospasm, aspiration, hypotension, or cardiac dysrhythmias) that reduces the intake of oxygen from the lungs, tissue hypoxia results.
The nurse is assessing a newly admitted medical patient and notes there is a depression in the lower portion of the patient's sternum. This patient's health record should note the presence of what chest deformity? A)A barrel chest B)A funnel chest C)A pigeon chest D)Kyphoscoliosis
B Feedback: A funnel chest occurs when there is a depression in the lower portion of the sternum, and this may lead to compression of the heart and great vessels, resulting in murmurs. A barrel chest is characterized by an increase in the anteroposterior diameter of the thorax and is a result of overinflation of the lungs. A pigeon chest occurs as a result of displacement of the sternum and includes an increase in the anteroposterior diameter. Kyphoscoliosis, which is characterized by elevation of the scapula and a corresponding S-shaped spine, limits lung expansion within the thorax
The nurse is performing a respiratory assessment of a patient who has been experiencing episodes of hypoxia. The nurse is aware that this is ultimately attributable to impaired gas exchange. On what factor does adequate gas exchange primarily depend? A)An appropriate perfusiondiffusion ratio B)An adequate ventilationperfusion ratio C)Adequate diffusion of gas in shunted blood D)Appropriate blood nitrogen concentration
B Feedback: Adequate gas exchange depends on an adequate ventilationperfusion ratio. There is no perfusiondiffusion ratio. Adequate gas exchange does not depend on the diffusion of gas in shunted blood or a particular concentration of nitrogen.
A patient with a decreased level of consciousness is in a recumbent position. How should the nurse best assess the lung fields for a patient in this position? A)Inform that physician that the patient is in a recumbent position and anticipate an order for a portable chest x-ray. B)Turn the patient to enable assessment of all the patient's lung fields. C)Avoid turning the patient, and assess the accessible breath sounds from the anterior chest wall. D)Obtain a pulse oximetry reading, and, if the reading is low, reposition the patient and auscultate breath sounds.
B Feedback: Assessment of the anterior and posterior lung fields is part of the nurse's routine evaluation. If the patient is recumbent, it is essential to turn the patient to assess all lung fields so that dependent areas can be assessed for breath sounds, including the presence of normal breath sounds and adventitious sounds. Failure to examine the dependent areas of the lungs can result in missing significant findings. This makes the other given options unacceptable.
The nurse is caring for a patient with lung metastases who just underwent a mediastinotomy. What should be the focus of the nurse's postprocedure care? A)Assisting with pulmonary function testing (PFT) B)Maintaining the patient's chest tube C)Administering oral suction as needed D)Performing chest physiotherapy
B Feedback: Chest tube drainage is required after mediastinotomy. PFT, chest physiotherapy, and oral suctioning would all be contraindicated because of the patient's unstable health status.
The nurse is assessing a patient who frequently coughs after eating or drinking. How should the nurse best follow up this assessment finding? A)Obtain a sputum sample. B)Perform a swallowing assessment. C)Inspect the patient's tongue and mouth. D)Assess the patient's nutritional status.
B Feedback: Coughing after food intake may indicate aspiration of material into the tracheobronchial tree; a swallowing assessment is thus indicated. Obtaining a sputum sample is relevant in cases of suspected infection. The status of the patient's tongue, mouth, and nutrition is not directly relevant to the problem of aspiration.
The nurse is caring for a patient who has a pleural effusion and who underwent a thoracoscopic procedure earlier in the morning. The nurse should prioritize assessment for which of the following? A)Sputum production B)Shortness of breath C)Throat discomfort D)Epistaxis
B Feedback: Follow-up care in the health care facility and at home involves monitoring the patient for shortness of breath (which might indicate a pneumothorax). All of the listed options are relevant assessment findings, but shortness of breath is the most serious complication.
A patient has been diagnosed with pulmonary hypertension, in which the capillaries in the alveoli are squeezed excessively. The nurse should recognize a disturbance in what aspect of normal respiratory function? A)Acidbase balance B)Perfusion C)Diffusion D)Ventilation
B Feedback: Perfusion is influenced by alveolar pressure. The pulmonary capillaries are sandwiched between adjacent alveoli and, if the alveolar pressure is sufficiently high, the capillaries are squeezed. This does not constitute a disturbance in ventilation (air movement), diffusion (gas exchange), or acidbase balance.
A sputum study has been ordered for a patient who has developed coarse chest crackles and a fever. At what time should the nurse best collect the sample? A)Immediately after a meal B)First thing in the morning C)At bedtime D)After a period of exercise
B Feedback: Sputum samples ideally are obtained early in the morning before the patient has had anything to eat or drink.
he nurse doing rounds at the beginning of a shift notices a sputum specimen in a container sitting on the bedside table in a patient's room. The nurse asks the patient when he produced the sputum specimen and he states that the specimen is about 4 hours old. What action should the nurse take? A)Immediately take the sputum specimen to the laboratory. B)Discard the specimen and assist the patient in obtaining another specimen. C)Refrigerate the sputum specimen and submit it once it is chilled. D)Add a small amount of normal saline to moisten the specimen.
B Feedback: Sputum samples should be submitted to the laboratory as soon as possible. Allowing the specimen to stand for several hours in a warm room results in the overgrowth of contaminated organisms and may make it difficult to identify the pathogenic organisms. Refrigeration of the sputum specimen and the addition of normal saline are not appropriate actions.
A gerontologic nurse is analyzing the data from a patient's focused respiratory assessment. The nurse is aware that the amount of respiratory dead space increases with age. What is the effect of this physiological change? A)Increased diffusion of gases B)Decreased diffusion capacity for oxygen C)Decreased shunting of blood D)Increased ventilation
B Feedback: The amount of respiratory dead space increases with age. Combined with other changes, this results in a decreased diffusion capacity for oxygen with increasing age, producing lower oxygen levels in the arterial circulation. Decreased shunting and increased ventilation do not occur with age.
A patient is having her tonsils removed. The patient asks the nurse what function the tonsils normally serve. Which of the following would be the most accurate response? A)The tonsils separate your windpipe from your throat when you swallow. B)The tonsils help to guard the body from invasion of organisms. C)The tonsils make enzymes that you swallow and which aid with digestion. D)The tonsils help with regulating the airflow down into your lungs.
B Feedback: The tonsils, the adenoids, and other lymphoid tissue encircle the throat. These structures are important links in the chain of lymph nodes guarding the body from invasion of organisms entering the nose and throat. The tonsils do not aid digestion, separate the trachea from the esophagus, or regulate airflow to the bronchi.
While assessing a patient who has pneumonia, the nurse has the patient repeat the letter E while the nurses auscultates. The nurse notes that the patient's voice sounds are distorted and that the letter A is audible instead of the letter E. How should this finding be documented? A)Bronchophony B)Egophony C)Whispered pectoriloquy D)Sonorous wheezes
B Feedback: This finding would be documented as egophony, which can be best assessed by instructing the patient to repeat the letter E. The distortion produced by consolidation transforms the sound into a clearly heard A rather than E. Bronchophony describes vocal resonance that is more intense and clearer than normal. Whispered pectoriloquy is a very subtle finding that is heard only in the presence of rather dense consolidation of the lungs. Sound is so enhanced by the consolidated tissue that even whispered words are heard. Sonorous wheezes are not defined as a voice sound, but rather as a breath sound.
A medical patient rings her call bell and expresses alarm to the nurse, stating, I've just coughed up this blood. That can't be good, can it? How can the nurse best determine whether the source of the blood was the patient's lungs? A)Obtain a sample and test the pH of the blood, if possible. B)Try to see if the blood is frothy or mixed with mucus. C)Perform oral suctioning to see if blood is obtained. D)Swab the back of the patient's throat to see if blood is present.
B Feedback: Though not definitive, blood from the lung is usually bright red, frothy, and mixed with sputum. Testing the pH of nonarterial blood samples is not common practice and would not provide important data. Similarly, oral suctioning and swabbing the patient's mouth would not reveal the source.
A patient asks the nurse why an infection in his upper respiratory system is affecting the clarity of his speech. Which structure serves as the patient's resonating chamber in speech? A)Trachea B)Pharynx C)Paranasal sinuses D)Larynx
C Feedback: A prominent function of the sinuses is to serve as a resonating chamber in speech. The trachea, also known as the windpipe, serves as the passage between the larynx and the bronchi. The pharynx is a tubelike structure that connects the nasal and oral cavities to the larynx. The pharynx also functions as a passage for the respiratory and digestive tracts. The major function of the larynx is vocalization through the function of the vocal cords. The vocal cords are ligaments controlled by muscular movements that produce sound.
A patient is undergoing testing to see if he has a pleural effusion. Which of the nurse's respiratory assessment findings would be most consistent with this diagnosis? A)Increased tactile fremitus, egophony, and a dull sound upon percussion of the chest wall B)Decreased tactile fremitus, wheezing, and a hyperresonant sound upon percussion of the chest wall C)Lung fields dull to percussion, absent breath sounds, and a pleural friction rub D)Normal tactile fremitus, decreased breath sounds, and a resonant sound upon percussion of the chest wall
C Feedback: Assessment findings consistent with a pleural effusion include affected lung fields being dull to percussion and absence of breath sounds. A pleural friction rub may also be present. The other listed signs are not typically associated with a pleural effusion.
The nurse is caring for an elderly patient in the PACU. The patient has had a bronchoscopy, and the nurse is monitoring for complications related to the administration of lidocaine. For what complication related to the administration of large doses of lidocaine in the elderly should the nurse assess? A)Decreased urine output and hypertension B)Headache and vision changes C)Confusion and lethargy D)jaundice and elevated liver enzymes
C Feedback: Lidocaine may be sprayed on the pharynx or dropped on the epiglottis and vocal cords and into the trachea to suppress the cough reflex and minimize discomfort during a bronchoscopy. After the procedure, the nurse will assess for confusion and lethargy in the elderly, which may be due to the large doses of lidocaine administered during the procedure. The other listed signs and symptoms are not specific to this problem.
The ED nurse is assessing the respiratory function of a teenage girl who presented with acute shortness of breath. Auscultation reveals continuous wheezes during inspiration and expiration. This finding is most suggestive what? A)Pleurisy B)Emphysema C)Asthma D)Pneumonia
C Feedback: Sibilant wheezes are commonly associated with asthma. They do not normally accompany pleurisy, emphysema, or pneumonia.
The nurse is completing a patient's health history with regard to potential risk factors for lung disease. What interview question addresses the most significant risk factor for respiratory diseases? A)Have you ever been employed in a factory, smelter, or mill? B)Does anyone in your family have any form of lung disease? C)Do you currently smoke, or have you ever smoked? D)Have you ever lived in an area that has high levels of air pollution?
C Feedback: Smoking the single most important contributor to lung disease, exceeds the significance of environmental, occupational, and genetic factors.
The nurse is caring for a patient admitted with an acute exacerbation of chronic obstructive pulmonary disease. During assessment, the nurse finds that the patient is experiencing increased dyspnea. What is the most accurate measurement of the concentration of oxygen in the patient's blood? A)A capillary blood sample B)Pulse oximetry C)An arterial blood gas (ABG) study D)A complete blood count (CBC)
C Feedback: The arterial oxygen tension (partial pressure or PaO2) indicates the degree of oxygenation of the blood, and the arterial carbon dioxide tension (partial pressure or PaCO2) indicates the adequacy of alveolar ventilation. ABG studies aid in assessing the ability of the lungs to provide adequate oxygen and remove carbon dioxide and the ability of the kidneys to reabsorb or excrete bicarbonate ions to maintain normal body pH. Capillary blood samples are venous blood, not arterial blood, so they are not as accurate as an ABG. Pulse oximetry is a useful clinical tool but does not replace ABG measurement, because it is not as accurate. A CBC does not indicate the concentration of oxygen.
The nurse is assessing the respiratory status of a patient who is experiencing an exacerbation of her emphysema symptoms. When preparing to auscultate, what breath sounds should the nurse anticipate? A)Absence of breath sounds B)Wheezing with discontinuous breath sounds C)Faint breath sounds with prolonged expiration D)Faint breath sounds with fine crackles
C Feedback: The breath sounds of the patient with emphysema are faint or often completely inaudible. When they are heard, the expiratory phase is prolonged.
A medical nurse has admitted a patient to the unit with a diagnosis of failure to thrive. The patient has developed a fever and cough, so a sputum specimen has been obtained. The nurse notes that the sputum is greenish and that there is a large quantity of it. The nurse notifies the patient's physician because these symptoms are suggestive of what? A)Pneumothorax B)Lung tumors C)Infection D)Pulmonary edema
C Feedback: The nature of the sputum is often indicative of its cause. A profuse amount of purulent sputum (thick and yellow, green, or rust-colored) or a change in color of the sputum is a common sign of a bacterial infection. Pink-tinged mucoid sputum suggests a lung tumor. Profuse, frothy, pink material, often welling up into the throat, may indicate pulmonary edema. A pneumothorax does not result in copious, green sputum.
While assessing an acutely ill patient's respiratory rate, the nurse assesses four normal breaths followed by an episode of apnea lasting 20 seconds. How should the nurse document this finding? A)Eupnea B)Apnea C)Biot's respiration D)Cheyne-Stokes
C Feedback: The nurse will document that the patient is demonstrating a Biot's respiration pattern. Biot's respiration is characterized by periods of normal breathing (three to four breaths) followed by varying periods of apnea (usually 10 seconds to 1 minute). Cheyne-Stokes is a similar respiratory pattern, but it involves a regular cycle where the rate and depth of breathing increase and then decrease until apnea occurs. Biot's respiration is not characterized by the increase and decrease in the rate and depth, as characterized by Cheyne-Stokes. Eupnea is a normal breathing pattern of 12 to 18 breaths per minute. Bradypnea is a slower-than-normal rate (<10 breaths per minute), with normal depth and regular rhythm, and no apnea.
A patient with chronic lung disease is undergoing lung function testing. What test result denotes the volume of air inspired and expired with a normal breath? A)Total lung capacity B)Forced vital capacity C)Tidal volume D)Residual volume
C Feedback: Tidal volume refers to the volume of air inspired and expired with a normal breath. Total lung capacity is the maximal amount of air the lungs and respiratory passages can hold after a forced inspiration. Forced vital capacity is vital capacity performed with a maximally forced expiration. Residual volume is the maximal amount of air left in the lung after a maximal expiration.
A patient has been diagnosed with heart failure that has not yet responded to treatment. What breath sound should the nurse expect to assess on auscultation? A)Expiratory wheezes B)Inspiratory wheezes C)Rhonchi D)Crackles
D Feedback: Crackles reflect underlying inflammation or congestion and are often present in such conditions as pneumonia, bronchitis, and congestive heart failure. Rhonchi and wheezes are associated with airway obstruction, which is not a part of the pathophysiology of heart failure.
The nurse is caring for a patient who has been scheduled for a bronchoscopy. How should the nurse prepare the patient for this procedure? A)Administer a bolus of IV fluids. B)Arrange for the insertion of a peripherally inserted central catheter. C)Administer nebulized bronchodilators every 2 hours until the test. D)Withhold food and fluids for several hours before the test.
D Feedback: Food and fluids are withheld for 4 to 8 hours before the test to reduce the risk of aspiration when the cough reflex is blocked by anesthesia. IV fluids, bronchodilators, and a central line are unnecessary.
The patient has just had an MRI ordered because a routine chest x-ray showed suspicious areas in the right lung. The physician suspects bronchogenic carcinoma. An MRI would most likely be order to assess for what in this patient? A)Alveolar dysfunction B)Forced vital capacity C)Tidal volume D)Chest wall invasion
D Feedback: MRI is used to characterize pulmonary nodules; to help stage bronchogenic carcinoma (assessment of chest wall invasion); and to evaluate inflammatory activity in interstitial lung disease, acute pulmonary embolism, and chronic thrombolytic pulmonary hypertension. Imaging would not focus on the alveoli since the problem in the bronchi. A static image such as MRI cannot inform PFT.
A patient is being treated for a pulmonary embolism and the medical nurse is aware that the patient suffered an acute disturbance in pulmonary perfusion. This involved an alteration in what aspect of normal physiology? A)Maintenance of constant osmotic pressure in the alveoli B)Maintenance of muscle tone in the diaphragm C)pH balance in the pulmonary veins and arteries D)Adequate flow of blood through the pulmonary circulation.
D Feedback: Pulmonary perfusion is the actual blood flow through the pulmonary circulation. Perfusion is not defined in terms of pH balance, muscle tone, or osmotic pressure.
In addition to heart rate, blood pressure, respiratory rate, and temperature, the nurse needs to assess a patient's arterial oxygen saturation (SaO2). What procedure will best accomplish this? A)Incentive spirometry B)Arterial blood gas (ABG) measurement C)Peak flow measurement D)Pulse oximetry
D Feedback: Pulse oximetry is a noninvasive procedure in which a small sensor is positioned over a pulsating vascular bed. It can be used during transport and causes the patient no discomfort. An incentive spirometer is used to assist the patient with deep breathing after surgery. ABG measurement can measure SaO2, but this is an invasive procedure that can be painful. Some patients with asthma use peak flow meters to measure levels of expired air.
The nurse is caring for a patient who has just returned to the unit after a colon resection. The patient is showing signs of hypoxia. The nurse knows that this is probably caused by what? A)Nitrogen narcosis B)Infection C)Impaired diffusion D)Shunting
D Feedback: Shunting appears to be the main cause of hypoxia after thoracic or abdominal surgery and most types of respiratory failure. Impairment of normal diffusion is a less common cause. Infection would not likely be present at this early stage of recovery and nitrogen narcosis only occurs from breathing compressed air.
A patient is scheduled to have excess pleural fluid aspirated with a needle in order to relieve her dyspnea. The patient inquires about the normal function of pleural fluid. What should the nurse describe? A)It allows for full expansion of the lungs within the thoracic cavity. B)It prevents the lungs from collapsing within the thoracic cavity. C)It limits lung expansion within the thoracic cavity. D)It lubricates the movement of the thorax and lungs.
D Feedback: The visceral pleura cover the lungs; the parietal pleura line the thorax. The visceral and parietal pleura and the small amount of pleural fluid between these two membranes serve to lubricate the thorax and lungs and permit smooth motion of the lungs within the thoracic cavity with each breath. The pleura do not allow full expansion of the lungs, prevent the lungs from collapsing, or limit lung expansion within the thoracic cavity.
A patient has a diagnosis of multiple sclerosis. The nurse is aware that neuromuscular disorders such as multiple sclerosis may lead to a decreased vital capacity. What does vital capacity measure? A)The volume of air inhaled and exhaled with each breath B)The volume of air in the lungs after a maximal inspiration C)The maximal volume of air inhaled after normal expiration D)The maximal volume of air exhaled from the point of maximal inspiration
D Feedback: Vital capacity is measured by having the patient take in a maximal breath and exhale fully through a spirometer. Vital lung capacity is the maximal volume of air exhaled from the point of maximal inspiration, and neuromuscular disorders such as multiple sclerosis may lead to a decreased vital capacity. Tidal volume is defined as the volume of air inhaled and exhaled with each breath. The volume of air in the lungs after a maximal inspiration is the total lung capacity. Inspiratory capacity is the maximal volume of air inhaled after normal expiration.
