Exam 3 Resp

On auscultation of a patient in respiratory distress, you hear a high-pitched, harsh sound that is monophonic and is present only during inspiration. This is known as:* A. Stridor B. Vesicular C. Rales D. Rhonchi

A

When auscultating the anterior part of the chest, specifically the apex of the lungs, it is best to auscultate where with the stethoscope?* A. Slightly above the clavicle B. 2nd intercostal space mid-clavicular C. 4th intercostal space mid-clavicular D. 6th intercostal space mid-axillary line

A

A 65-year-old man presents with a chronic productive cough, dyspnea, and wheezing. Examination reveals cyanosis, distended neck veins, and a prominent epigastric pulsation. What is the most likely diagnosis? A. cor pulmonale B. chronic bronchitis C. emphysema D. pneumonia

A Cor pulmonale is right ventricular hypertrophy and failure resulting from pulmonary disease. It is most commonly caused by chronic obstructive pulmonary disease, which is this patient's underlying disorder precipitating the failure. While the other three diagnoses may have similar symptoms, none of them would present with distended neck veins and prominent epigastric pulsations.

7. A patient is receiving mechanical ventilation with PEEP. The patient had developed a tension pneumothorax. Select ALL the signs and symptoms that can present with this condition:* A. Hypotension B. Jugular Venous Distention C. Bradycardia D. Tracheal deviation E. Hyperemia F. Tachypnea

A, B, D, F

A nurse is supervising a student nurse who is performing tracheostomy care for a client. Which of the following actions by the student should the nurse intervene? A. Removing the inner cannula and cleaning using universal precaution. B. Suctioning the tracheostomy tube before performing tracheostomy care. C. Changing the old tracheotomy ties and securing the tube in place. D. Replacing the inner cannula and cleaning the site of the stoma.

A. When performing tracheostomy care, a sterile field is set up and sterile technique is required. Standard precautions such as washing hands must also be maintained but are not enough when performing tracheostomy care. The presence of tracheostomy tube provides direct access to the lungs for organisms, so sterile technique is used to prevent infection.

You are providing pre-opt teaching to a patient who will be having abdominal surgery. After discussing with the patient how to use an incentive spirometer, you ask the patient to demonstrate how to use the device. Which action by the patient demonstrates that the patient understood your education about how to use the device? A. The patient inhales quickly and rapidly off of the device. B. The patient inhales and then exhales into the mouthpiece. C. The patient inhales slowly until unable and holds breath for 6 seconds and then exhales. D. The patient slowly inhales and exhales multiple times and then holds breath for 2 seconds.

Answer: C A is wrong because the patient should SLOWLY inhale from the device not quickly and rapidly. B is wrong because the patient never exhales into the mouthpiece. D is wrong because the patient should inhale and exhale one time each time (not multiple) and hold breath for 6 seconds...not two.

1. A patient is admitted with a chest wound and experiencing extreme dyspnea, tachycardia, and hypoxia. The chest wound is located on the left mid-axillary area of the chest. On assessment, you note there is unequal rise and fall of the chest with absent breath sounds on the left side. You also note a "sucking" sound when the patient inhales and exhales. The patient's chest x-ray shows a pneumothorax. What type of pneumothorax is this known as?* A. Closed pneumothorax B. Open pneumothorax C. Tension pneumothorax D. Spontaneous pneumothorax

B

8. A patient has a chest tube for treatment of a pneumothorax in the left lung. Which finding during your assessment requires immediate nursing intervention? A. The water seal chamber has intermittent bubbling. B. The patient has slight tracheal deviation to the right side. C. The water seal chamber fluctuates while the patient inhales and exhales. D. The patient complains of tenderness at the chest tube insertion site.

B

9. Which statement is CORRECT about a tension pneumothorax? A. This condition happens when an opening to the intrapleural space creates a two-way valve which causes pressure to build up in the space leading to shifting of the mediastinum. B. A tension pneumothorax is a medical emergency and is treated with needle decompression. C. Tracheal deviation is an early sign of a tension pneumothorax D. An open pneumothorax is the only cause of a tension pneumothorax.

B

A newly RN nurse is about to insert a nasogastric tube to a client with Guillan Barre Syndrome. To determine the accurate measurement of the length of the tube be inserted, the nurse should: A. Place the tube at the tip of the nose, and measure by extending the tube to the earlobe and then down to the top of the sternum. B. Place the tube at the tip of the nose, and measure by extending the tube to the earlobe and then down to the xiphoid process. C. Place the tube at the tip of the nose, and measure by extending the tube down to the chin and then down to the top of the xiphoid process. D. Place the tube at the base of the nose, and measure by extending the tube to the earlobe and then down to the top of the sternum.

B

The right middle lobe is auscultated with the stethoscope where?* A. Posteriorly on the right at the 4th intercostal space B. Anteriorly on the right at the 4th intercostal space C. Anteriorly between C7 to T3 D. Posteriorly between T3 to T10

B

These breath sounds are found anteriorly and posteriorly throughout the peripheral lung fields?* A. High-pitched wheezes B. Vesicular C. Discontinuous D. Bronchial

B

A 62-year-old woman with pulmonary hypertension called 911 complaining of sweating and difficulty in breathing. Upon arrival to her home the paramedics found her to have pallor, diaphoresis, tachypnea, hypotension, and tachycardia. Her pulse oximetry was 89%, so they gave her oxygen via nonrebreather mask and transported her to the emergency department (ED). She was not complaining of angina. The ED physician assistant noted her to be in acute distress with elevated jugular venous pressure, a medial heave, a tender palpable liver, a systolic murmur of tricuspid regurgitation, and an S4 gallop. ECG demonstrated right axis deviation and right ventricular hypertrophy with no ST-T changes. Her arterial blood gas (ABG) demonstrated a low PaO2 and a low PaCO2. What is her likely diagnosis? A. acute coronary syndrome B. cor pulmonale C. heart failure D. pulmonary embolus

B Patients with all of these conditions may be diaphoretic and complaining of dyspnea. Marked hypotension in acute coronary syndrome occurs when the right coronary artery is affected. Acute coronary syndromes do not usually present with systolic murmurs, but patients will complain of angina and the ECG changes will include ST-segment changes. Patients who have severe heart failure will have similar symptoms but also have pulsus alternans and pulmonary rales. Finally, patients with pulmonary embolus may have hemodynamic changes but usually have a low PaO2 and a normal PaCO2. ECG may show right-axis deviation in a pulmonary embolus as well.

The nurse caring for a client with a pneumothorax and who has had a chest tube inserted notes continuous gentle bubbling in the suction control chamber. What action is most appropriate of the nurse? A. Increase the suction pressure so that the bubbling becomes vigorous. B. Do nothing since this is an expected finding. C. Immediately clamp the chest tube and notify the physician. D. Check for an air leak because the bubbling should be intermittent.

B Continuous gentle bubbling should be noted in the suction control chamber. Bubbling should be continuous in the suction control chamber and not intermittent. Option A: Increasing the suction pressure only increases the rate of evaporation of water in the drainage system. and this is not done without any prescription of the physician. Options C and D: Chest tubes should only be clamped to check for an air leak or when changing drainage devices.

The nurse is assessing a client with an endotracheal tube and observes that the client can make verbal sounds. What is the most likely cause of this? A. This is a normal finding. B. There is a leak. C. There is an occlusion. D. The endotracheal tube is displaced

B When conducting the minimal leak technique the client should not be able to make verbal sounds or no air should be felt coming out of the client's mouth.

A stroke client who was initially on NGT feeding was able to tolerate soft diet so the physician ordered for the removal of it. The nurse would instruct the client to do which of the following before he removes the tube? A. Inhale and exhale simultaneously. B. Take a long breath and hold it. C. Do a Valsalva maneuver. D. Blow the nose.

B. Holding the breath closes the glottis hence it will be easier to withdraw the tube through the esophagus into the nose. and this method will also prevent aspiration.

2. In regards to the patient in the question above, which of the following options below is a nursing intervention you would provide to this patient?* A. Place the patient in supine position B. Place a non-occlusive dressing over the chest wound C. Place a sterile occlusive dressing over the chest wound and tape it on three sides D. Prepare the patient for a thoracentesis

C

4. Which of the following is a LATE sign of the development of a tension pneumothorax?* A. Hypotension B. Tachycardia C. Tracheal deviation D. Dyspnea

C

5. While caring for a patient with a suspected pneumothorax, you note there are several areas on the patient's skin that appear to be "bulging" out. These "bulging" areas are located on the patient's neck, face, and abdomen. On palpation on these areas, you note they feel "crunchy". When charting your findings you would refer to this finding as?* A. Subcutaneous paresthesia B. Pigment molle C. Subcutaneous emphysema D. Veisalgia

C

6. You're providing care to a patient with a pneumothorax who has a chest tube. On assessment of the chest tube system, you note there is no fluctuation of water in the water seal chamber as the patient inhales and exhales. You check the system for kinks and find none. What is your next nursing action?* A. Keep monitoring the patient because this is a normal finding. B. Increase wall suction to the system until the water fluctuates in the water seal chamber. C. Assess patient's lung sounds to assess if the affected lung has re-expanded. D. Notify the physician.

C

These type of breath sounds are found at the site of the bronchi and are located anteriorly at the 1st and 2nd intercostal space & posteriorly in between the scapulae?* A. Crackles B. Wheezes C. Bronchovesicular D. Vesicular

C

This lung sound is continuous, high-pitched with musical instrument sound that is polyphonic and occurs mainly during expiration but can be present with inspiration as well?* A. Stridor B. Fine crackles C. High-pitched wheeze D. High-pitched crackles

C

When auscultating the posterior part of the chest the upper lobes are found?* A. Between C9 to T10 B. Between T3 to T10 C. Between C7 to T3 D. Directly over the scapulae

C

While assessing a patient's lung sounds you note bronchial breath sounds in the peripheral lung fields. What could this finding represent?* A. This is a normal finding. B. Pulmonary emboli C. Lung consolidation like with pneumonia D. Pleuritis

C

You are auscultating a patient's lung sounds. During your assessment, you note there is a low-pitched harsh, grating sound that sounds like a pleural friction rub. However, you're not sure if this is a pleural friction rub or pericardial friction rub. What do you do next to determine the difference?* A. Have the patient cough and see if the sound clears B. Assess the posterior lower lobe only C. Have the patient hold their breath and note if the sound is still present D. Place the patient in supine position and reassess for the sound

C

After the client had tolerated the weaning process, the physician ordered the removal of the endotracheal tube and will be shifted into a nasal cannula. Which of the following findings after the removal requires immediate intervention by the physician? A. Sore throat. B. Hoarseness of the voice. C. Coughing out blood. D. Neck discomfort.

C A sign of a tracheal or esophageal perforation which prevents oxygen from reaching the lungs and can result in internal bleeding. This life-threatening side effect of being intubated requires immediate medical intervention. Options A, B, and D are normal and that the client should limit talking if it occurs.

Continuous type of feedings is administered over a __ hour period.? A. 4. B. 12. C. 24. D. 36.

C Continuous feeding is administered for 24 hours. An infusion pump regulates the flow.

The nurse is handling a client with a chest tube. Suddenly, the chest drainage system is accidentally disconnected, what is the most appropriate action for the nurse to take? A. Secure the chest tube using a tape. B. Clamp the chest tube immediately. C. Place the end of the chest tube in a container of normal sterile saline. D. Apply an occlusive dressing and notify the physician.

C If a chest drainage system is disconnected, the nurse can place the end of the chest tube in a container of normal sterile saline to prevent air from entering the chest tube, thereby preventing negative respiratory pressure. Option A: The nurse should tape the chest tube securely to prevent it from being disconnected, rather than taping it after it has been disconnected. Option B: The nurse should not clamp the chest tube because doing so increases the risk of tension pneumothorax. Option D: The nurse should apply an occlusive dressing if the chest tube is pulled out and not if the system is disconnected.

A client is subjected to undergo a chest x-ray to confirm the endotracheal tube placement. The tube should be how many centimeters above the carina? A. 2-4 cm. B. 1.5-3 cm. C. 1.5-3 cm. D. 0.5-1 cm.

C Placement of an endotracheal tube is confirmed by a chest x-ray and the correct placement is 1 to 2 cm above the carina.

Select all of the following that are considered discontinuous breath sounds:* A. High-pitched wheeze B. Stridor C. Pleural friction rub D. Fine crackles E. Low-pitched wheeze F. Coarse Crackles

C, D, F

Which of the following is not true regarding the types of a nasogastric tube? A. Cantor tube is a single-lumen long tube with a small inflatable bag at the distal end. B. Miller-Abbott tube is a long double-lumen used to drain and d decompress the small intestine. C. Levin tube is a double lumen nasogastric tube with an air vent. D. Sengstaken-Blakemore tube is a three-lumen tube.

C. A levin tube is a single lumen nasogastric tube while a Salem sump tube is the double lumen nasogastric tube with an air vent.

The nurse is assessing the functioning of a chest tube drainage system in a client with hemothorax. Which of the following findings should prompt the nurse to notify the physician? A. Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation. B. Drainage system maintained below the client's chest. C. Drainage amount of 100ml in the drainage collection chamber. D. Occlusive dressing in place over the chest tube insertion site.

C. Drainage of more than 70 to 100 mL/hour is not normal and requires the immediate notification of the physician.

10. A patient receiving treatment for a pneumothorax calls on the call light to tell you something is wrong with their chest tube. When you arrive to the room you note that the drainage system has fallen on its side, and there is a large crack in the system. What is your next PRIORITY? A. Place the patient in supine position and clamp the tubing. B. Notify the physician immediately. C. Disconnect the drainage system and get a new one. D. Disconnect the tubing from the drainage system and insert the tubing 1 inch into a bottle of sterile water and obtain a new system.

D

3. A patient is diagnosed with a primary spontaneous pneumothorax. Which of the following is NOT a correct statement about this type of pneumothorax?* A. It can be caused by the rupture of a pulmonary bleb. B. It can occur in patients who are young, tall and thin without a history of lung disease. C. Smoking increases the chances of a patient developing a spontaneous pneumothorax. D. It is most likely to occur in patients with COPD, asthma, and cystic fibrosis.

D

Bronchial breath sounds can be auscultated where?* A. Peripheral lung fields B. Sternal area C. Mid-scapulae area D. Tracheal area

D

While changing the tapes on a tracheostomy tube, the client coughs and the tube is dislodged. Which is the initial nursing action? A. Call a respiratory therapist to reinsert the tracheotomy. B. Cover the tracheostomy site with a sterile dressing. C. Call the physician to reinsert the tracheotomy. D. Grasp the retention sutures to spread the opening

D If the tube is dislodged accidentally, the initial nursing action is to grasp the retention sutures and spread the opening. Options A and C: Calling respiratory therapist or the physician will delay treatment in this emergency situation. Option B: Covering the tracheostomy site will block the airway.

A nurse is checking the nasogastric tube position of a client receiving a long-term therapy of Omeprazole (Prisolec) by aspirating the stomach contents to check for the PH level. The nurse proves that correct tube placement if the PH level is? A. 7.75. B. 7.5. C. 6.5. D. 5.5.

D. Gastric placement is indicated by a pH of less than 4, but may increase to between pH 4-6 if the patient is receiving acid-inhibiting drugs.

The nurse is preparing to give bolus enteral feedings via a nasogastric tube to a comatose client. Which of the following actions is an inappropriate practice by the nurse? A. If bowel sounds are absent, hold the feeding and notify the physician. B. Assess tube placement by aspirating gastric content and check the PH level. C. Warm the feeding to room temperature to prevent the occurrence of diarrhea and cramps. D. Elevate the head of the bed to 45 degrees and maintains for 30 minutes after instillation of feeding.

D. If the client is comatose, place in a high-fowlers which is in a 90-degree level.

Before feeding a client via NGT, the nurse checks for residual and obtains a residual amount of 90ml. What is the appropriate action for the nurse to take? A. Discard the residual amount. B. Hold the due feeding. C. Skip the feeding and administer the next feeding due in 4 hours. D. Reinstill the amount and continue with administering the feeding.

D. If the residual feeding is less than 100ml, feeding is administered.

True or False: Low-pitched wheezes are polyphonic sounds that can be cleared when coughing. True False

False

True or False: The left lung has 3 lobes: left upper lobe, left middle lobe, and left lower lobe. True False

False

True or False: During auscultation, the anterior part of the chest mainly provides an assessment of the upper lobes of the right and left lungs, while the posterior part of the chest provides mainly provides an assessment of the lower lobes of the right and left lungs.* True False

True