Ch 25: Assessment of the Respiratory System

When assessing activity-exercise patterns related to respiratory health, the nurse inquires about a. dyspnea during rest or exercise b. recent weight loss or weight gain c. ability to sleep through the entire night d. willingness to wear O2 equipment in public

A Rationale: In this functional health pattern, determine whether the patient's activity is limited by dyspnea at rest or during exercise.

When teaching a patient about the most important respiratory defense mechanism distal to the respiratory bronchioles, which topic would the nurse discuss? a. Alveolar macrophages b. Impaction of particles c. Reflex bronchoconstriction d. Mucociliary clearance mechanism

A Rationale: Respiratory defense mechanisms are efficient in protecting the lungs from inhaled particles, microorganisms, and toxic gases. Because ciliated cells are not found below the level of the respiratory bronchioles, the primary defense mechanism at the alveolar level is alveolar macrophages.

To promote the release of surfactant, the nurse encourages the patient to a. take deep breaths b. cough five times per hour to prevent alveolar collapse c. decrease fluid intake to reduce fluid accumulation in the alveoli d. sit with head of bed elevated to promote air movement through the pores of Kohn

A Rationale: Surfactant is a lipoprotein that lowers the surface tension in the alveoli. It reduces the amount of pressure needed to inflate the alveoli and decreases the tendency of the alveoli to collapse. Deep breaths stretch the alveoli and promote surfactant secretion.

The nurse is preparing the patient for a diagnostic procedure to remove pleural fluid for analysis. The nurse would prepare the patient for which test? a. Thoracentesis b. Bronchoscopy c. Pulmonary angiography d. Sputum culture and sensitivity

A Rationale: Thoracentesis is the insertion of a large-bore needle through the chest wall into the pleural space to obtain specimens for diagnostic evaluation, remove pleural fluid, or instill medication.

The patient's arterial blood gas results show the PaO2 at 65 mmHg and SaO2 at 80%. What early manifestations should the nurse expect to observe in this patient? a. Restlessness, tachypnea, tachycardia, and diaphoresis b. Unexplained confusion, dyspnea at rest, hypotension, and diaphoresis c. Combativeness, retractions with breathing, cyanosis, and decreased output d. Coma, accessory muscle use, cool and clammy skin, and unexplained fatigue

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

A student nurse asks the RN what can be measured by arterial blood gas (ABG). The RN tells the student that the ABG can measure (select all that apply) a. acid-base balance b. oxygenation status c. acidity of the blood d. bicarbonate (HCO3-) in arterial blood e. overall balance of electrolytes in arterial blood

A, B, C, D Rationale: Arterial blood gases (ABGs) are measured to determine oxygenation status, ventilation status, and acid-base balance. ABG analysis includes measurement of the partial pressure of oxygen in arterial blood (PaO2), partial pressure of carbon dioxide in arterial blood (PaCO2), acidity (pH), bicarbonate (HCO3-), and arterial oxygen saturation (SaO2) in arterial blood. The overall balance of electrolytes cannot be determined with ABGs.

A diabetic patient's arterial blood gas (ABG) results are pH 7.28; PaCO2 34 mm Hg; PaO2 85 mm Hg; HCO3- 18 mEq/L. The nurse would expect which finding? a. Intercostal retractions b. Kussmaul respirations c. Low oxygen saturation (SpO2) d. Decreased venous O2 pressure

ANS: B Kussmaul (deep and rapid) respirations are a compensatory mechanism for metabolic acidosis. The low pH and low bicarbonate result indicate metabolic acidosis. Intercostal retractions, a low oxygen saturation rate, and a decrease in venous O2 pressure would not be caused by acidosis

The nurse is performing an assessment of the client's respiratory system. Which of the following parameters is the nurse assessing when using the following illustrated technique? (Pt is facing away and both hands are wrapped around the pt's back below the shoulder blades)

B

Which of the following respiratory assessments are not normal? (Select all that apply.) a. Respirations 23 breaths/minute b. Outward movement of abdomen during inspiration c. Increase in vibrations with tactile fremitus d. Tripod position e. Symmetrical chest expansion

ACD

A patient with acute dyspnea is scheduled for a spiral computed tomography (CT) scan. Which information obtained by the nurse is a priority to communicate to the health care provider before the CT? a. Allergy to shellfish b. Apical pulse of 104 c. Respiratory rate of 30 d. Oxygen saturation of 90%

ANS: A Because iodine-based contrast media is used during a spiral CT, the patient may need to have the CT scan without contrast or be premedicated before injection of the contrast media. The increased pulse, low oxygen saturation, and tachypnea all indicate a need for further assessment or intervention but do not indicate a need to modify the CT procedure

On auscultation of a patient's lungs, the nurse hears low-pitched, bubbling sounds during inhalation in the lower third of both lungs. How should the nurse document this finding? a. Inspiratory crackles at the bases b. Expiratory wheezes in both lungs c. Abnormal lung sounds in the apices of both lungs d. Pleural friction rub in the right and left lower lobes

ANS: A Crackles are low-pitched, bubbling sounds usually heard on inspiration. Wheezes are high-pitched sounds. They can be heard during the expiratory or inspiratory phase of the respiratory cycle. The lower third of both lungs are the bases, not apices. Pleural friction rubs are grating sounds that are usually heard during both inspiration and expiration

A patient is admitted to the emergency department complaining of sudden onset shortness of breath and is diagnosed with a possible pulmonary embolus. How should the nurse prepare the patient for diagnostic testing to confirm the diagnosis? a. Start an IV so contrast media may be given. b. Ensure that the patient has been NPO for at least 6 hours. c. Inform radiology that radioactive glucose preparation is needed. d. Instruct the patient to undress to the waist and remove any metal objects.

ANS: A Spiral computed tomography (CT) scans are the most commonly used test to diagnose pulmonary emboli, and contrast media may be given IV. A chest x-ray may be ordered but will not be diagnostic for a pulmonary embolus. Preparation for a chest x-ray includes undressing and removing any metal. Bronchoscopy is used to detect changes in the bronchial tree, not to assess for vascular changes, and the patient should be NPO 6 to 12 hours before the procedure. Positron emission tomography (PET) scans are most useful in determining the presence of malignancy, and a radioactive glucose preparation is used

The nurse assesses 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 for the nurse to report to the health care provider? a. Respirations are 36 breaths/minute. b. Anterior-posterior chest ratio is 1:1. c. Lung expansion is decreased bilaterally. d. Hyperresonance to percussion is present.

ANS: A The increase in respiratory rate indicates respiratory distress and a need for rapid interventions such as administration of oxygen or medications. The other findings are common chronic changes occurring in patients with COPD

After the nurse has received change-of-shift report, which patient should the nurse assess first? a. A patient with pneumonia who has crackles in the right lung base b. A patient with possible lung cancer who has just returned after bronchoscopy c. A patient with hemoptysis and a 16-mm induration with tuberculin skin testing d. A patient with chronic obstructive pulmonary disease (COPD) and pulmonary function testing (PFT) that indicates low forced vital capacity

ANS: B Because the cough and gag are decreased after bronchoscopy, this patient should be assessed for airway patency. The other patients do not have clinical manifestations or procedures that require immediate assessment by the nurse

Which action is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)? a. Listen to a patient's lung sounds for wheezes or rhonchi. b. Label specimens obtained during percutaneous lung biopsy. c. Instruct a patient about how to use home spirometry testing. d. Measure induration at the site of a patient's intradermal skin test.

ANS: B Labeling of specimens is within the scope of practice of UAP. The other actions require nursing judgment and should be done by licensed nursing personnel

In assessment of the patient with acute respiratory distress, what should the nurse expect to observe (select all that apply.)? a. Cyanosis b. Tripod position c. Kussmaul respirations d. Accessory muscle use e. Increased AP diameter

B, D Tripod position and accessory muscle use indicate moderate to severe respiratory distress. Cyanosis may be related to anemia, decreased oxygen transfer in the lungs, or decreased cardiac output. Therefore, it is a nonspecific and unreliable indicator of only respiratory distress. Kussmaul respirations occur when the patient is in metabolic acidosis to increase CO2 excretion. Increased AP diameter occurs with lung hyperinflation from chronic obstructive pulmonary disease, cystic fibrosis, or with advanced age.

After the nurse has received change-of-shift report, which of the following clients should be assessed first? a. A client with pneumonia who has crackles in the right lung base b. A client with chronic obstructive pulmonary disease (COPD) and pulmonary function testing (PFT) that indicates low forced vital capacity c. A client with possible lung cancer who has just returned after bronchoscopy d. A client with hemoptysis and a 16-mm induration with tuberculin skin testing

C

The nurse is assessing the respiratory system of an older-adult client. Which of the following findings indicate that the nurse should take immediate action? a. The chest appears barrel shaped. b. The client has a weak cough effort. c. Crackles are heard from the lung bases to the midline. d. Hyperresonance is present across both sides of the chest.

C

The nurse is auscultating a client's chest while the client takes a deep breath and hears loud, high-pitched, "blowing" sounds at both lung bases. Which of the following information should the nurse document? a. Normal sounds b. Vesicular sounds c. Abnormal sounds d. Adventitious sounds

C

The nurse is caring for a client with respiratory disease and observes that the client's SpO2 drops from 92% to 88% while the client is ambulating in the hallway. Which of the following actions should the nurse take next? a. Notify the health care provider. b. Document the response to exercise. c. Administer the PRN supplemental O2. d. Encourage the client to pace activity.

C

The nurse is observing a student who is listening to a client's lungs. Which of the following actions by the student indicates a need to review respiratory assessment skills? a. The student compares breath sounds from side to side. b. The student listens only over the posterior part of the chest. c. The student places the stethoscope over the scapulae and then auscultates. d. The student starts at the base of the posterior lung and moves to the apices.

C

The nurse is palpating the posterior chest of a client while the client says "99" and notes that no vibration is felt. Which of the following information should the nurse document? a. Diminished expansion b. Dullness to percussion c. Absent tactile fremitus d. Decreased breath sounds

C

The nurse is reviewing a client's laboratory results and identifies which of the following values as a normal tidal volume? a. 100 mL b. 250 mL c. 500 mL d. 1 000 mL

C

During the respiratory assessment of an older adult, the nurse would expect to find (select all that apply) a. a vigorous reflex cough b. increased chest expansion c. increased residual volume d. diminished lung sounds at base of lungs e. increased anteroposterior (AP) chest diameter

C, D, E Rationale: The anterior-posterior diameter of the thoracic cage and the residual volume increase in older adults. An older adult has a less forceful cough. The costal cartilages calcify with aging and interfere with chest expansion. Decreased breath sounds at the base of lungs is also a common finding in older adults.

The nurse is assessing a client with chronic obstructive pulmonary disease (COPD) with increasing dyspnea over the last 3 days. Which of the following findings is most important to report to the health care provider? a. Respirations are 36 breaths/minute. b. Anterior-posterior chest ratio is 1:1. c. Lung expansion is decreased bilaterally. d. Hyperresonance to percussion is present.

A

A frail 82-yr-old female patient develops sudden shortness of breath while sitting in a chair. What location on the chest should the nurse begin auscultation of the lung fields? a. Bases of the posterior chest area b. Apices of the posterior lung fields c. Anterior chest area above the breasts d. Midaxillary on the left side of the chest

A Baseline data with the most information is best obtained by auscultation of the posterior chest, especially in female patients because of breast tissue interfering with the assessment or if the patient may tire easily (e.g., shortness of breath, dyspnea, weakness, fatigue). Usually auscultation proceeds from the lung apices to the bases unless it is possible the patient will tire easily. In this case, the nurse should start at the bases.

What should the nurse inspect when assessing a patient with shortness of breath for evidence of long-standing hypoxemia? a. Fingernails b. Chest excursion c. Spinal curvatures d. Respiratory pattern

A Clubbing, a sign of long-standing hypoxemia, is evidenced by an increase in the angle between the base of the nail and fingernail to 180 degrees or more, usually accompanied by an increase in the depth, bulk, and sponginess of the end of the finger.

The nurse is obtaining a focused respiratory assessment of a 44-yr-old female patient who is in severe respiratory distress 2 days after abdominal surgery. What is most important for the nurse to assess? a. Auscultation of bilateral breath sounds b. Percussion of anterior and posterior chest wall c. Palpation of the chest bilaterally for tactile fremitus d. Inspection for anterior and posterior chest expansion

A Important assessments obtained during a focused respiratory assessment include auscultation of lung (breath) sounds. Assessment of tactile fremitus has limited value in acute respiratory distress. It is not necessary to assess for both anterior and posterior chest expansion. Percussion of the chest wall is not essential in a focused respiratory assessment.

The patient with Parkinson's disease has a pulse oximetry reading of 72%, but he is not displaying any other signs of decreased oxygenation. What is most likely contributing to his low SpO2 level? a. Artifact b. Anemia c. Dark skin color d. Thick acrylic nails

A Motion is the most likely cause of the low SpO2 for this patient with Parkinson's disease. Anemia, dark skin color, and thick acrylic nails as well as low perfusion, bright fluorescent lights, and intravascular dyes may also cause an inaccurate pulse oximetry result. There is no mention of these or reason to suspect these in this question.

A patient with recurrent shortness of breath has just had a bronchoscopy. What is a priority nursing action immediately after the procedure? a. Monitor the patient for laryngeal edema. b. Assess the patient's level of consciousness. c. Monitor and manage the patient's level of pain. d. Assess the patient's heart rate and blood pressure.

A Priorities for assessment are the patient's airway and breathing, both of which may be compromised after bronchoscopy by laryngeal edema. These assessment parameters supersede the importance of loss of consciousness (LOC), pain, heart rate, and blood pressure, although the nurse should also be assessing these.

When assessing a patient's sleep-rest pattern related to respiratory health, what should the nurse ask the patient (select all that apply.)? a. Do you awaken abruptly during the night? b. Do you sleep more than 8 hours per night? c. Do you need to sleep with the head elevated? d. Do you often need to urinate during the night? e. Do you toss and turn when trying to fall asleep?

A, C, E A patient with obstructive sleep apnea may have insomnia, abrupt awakenings, or both. 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 8 hours per night or needing to urinate during the night is not indicative of impaired respiratory health.

A patient with a chronic cough has a bronchoscopy. After the procedure, which intervention by the nurse is most appropriate? a. Elevate the head of the bed to 80 to 90 degrees. b. Keep the patient NPO until the gag reflex returns. c. Place on bed rest for at least 4 hours after bronchoscopy. d. Notify the health care provider about blood-tinged mucus.

ANS: B Risk for aspiration and maintaining an open airway is the priority. 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. Blood-tinged mucus is not uncommon after bronchoscopy. The patient does not need to be on bed rest, and the head of the bed does not need to be in the high-Fowler's position

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? a. Ask the patient to lie down to complete a full physical assessment. b. Briefly ask specific questions about this episode of respiratory distress. c. Complete the admission database to check for allergies before treatment. d. Delay the physical assessment to first complete pulmonary function tests.

ANS: B 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. Obtaining a comprehensive health history or full physical examination is unnecessary until the acute distress has resolved. Brief questioning and a focused physical assessment should be done rapidly to help determine the cause of the distress and suggest treatment. Checking for allergies is important, but it is not appropriate to complete the entire admission database at this time. The initial respiratory assessment must be completed before any diagnostic tests or interventions can be ordered

A patient is scheduled for a computed tomography (CT) of the chest with contrast media. Which assessment findings should the nurse immediately report to the health care provider (select all that apply)? a. Patient is claustrophobic. b. Patient is allergic to shellfish. c. Patient recently used a bronchodilator inhaler. d. Patient is not able to remove a wedding band. e. Blood urea nitrogen (BUN) and serum creatinine levels are elevated.

ANS: B, E Because the contrast media is iodine-based and may cause dehydration and decreased renal blood flow, asking about iodine allergies (such as allergy to shellfish) and monitoring renal function before the CT scan are necessary. The other actions are not contraindications for CT of the chest, although they may be for other diagnostic tests, such as magnetic resonance imaging (MRI) or pulmonary function testing (PFT).

A patient in metabolic alkalosis is admitted to the emergency department, and pulse oximetry (SpO2) indicates that the O2 saturation is 94%. Which action should the nurse take next? a. Administer bicarbonate. b. Complete a head-to-toe assessment. c. Place the patient on high-flow oxygen. d. Obtain repeat arterial blood gases (ABGs).

ANS: C 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. Bicarbonate would worsen the patient's condition. A head-to-toe assessment and repeat ABGs may be implemented. However, the priority intervention is to give high-flow oxygen

The nurse completes a shift assessment on a patient admitted in the early phase of heart failure. When auscultating the patient's lungs, which finding would the nurse most likely hear? a. Continuous rumbling, snoring, or rattling sounds mainly on expiration b. Continuous high-pitched musical sounds on inspiration and expiration c. Discontinuous, high-pitched sounds of short duration heard on inspiration d. A series of long-duration, discontinuous, low-pitched sounds during inspiration

ANS: C Fine crackles are likely to be heard in the early phase of heart failure. Fine crackles are discontinuous, high-pitched sounds of short duration heard on inspiration. Rhonchi are continuous rumbling, snoring, or rattling sounds mainly on expiration. Course crackles are a series of long-duration, discontinuous, low-pitched sounds during inspiration. Wheezes are continuous high-pitched musical sounds on inspiration and expiration

The nurse teaches a patient about pulmonary function testing (PFT). Which statement, if made by the patient, indicates teaching was effective? a. "I will use my inhaler right before the test." b. "I won't eat or drink anything 8 hours before the test." c. "I should inhale deeply and blow out as hard as I can during the test." d. "My blood pressure and pulse will be checked every 15 minutes after the test."

ANS: C For PFT, the patient should inhale deeply and exhale as long, hard, and fast as possible. The other actions are not needed with PFT. The administration of inhaled bronchodilators should be avoided 6 hours before the procedure.

The nurse observes a student who is listening to a patient's lungs who is having no problems with breathing. Which action by the student indicates a need to review respiratory assessment skills? a. The student starts at the apices of the lungs and moves to the bases. b. The student compares breath sounds from side to side avoiding bony areas. c. The student places the stethoscope over the posterior chest and listens during inspiration. d. The student instructs the patient to breathe slowly and a little more deeply than normal through the mouth.

ANS: C Listening only during inspiration indicates the student needs a review of respiratory assessment skills. At each placement of the stethoscope, listen to at least one cycle of inspiration and expiration. During chest auscultation, instruct the patient to breathe slowly and a little deeper than normal through the mouth. Auscultation should proceed from the lung apices to the bases, comparing opposite areas of the chest, unless the patient is in respiratory distress or will tire easily. If so, start at the bases (see Fig. 26-7). Place the stethoscope over lung tissue, not over bony prominences.

While caring for a patient with respiratory disease, the nurse observes that the patient's SpO2 drops from 93% to 88% while the patient is ambulating in the hallway. What is the priority action of the nurse? a. Notify the health care provider. b. Document the response to exercise. c. Administer the PRN supplemental O2. d. Encourage the patient to pace activity.

ANS: C The drop in SpO2 to 85% indicates that the patient is hypoxemic and needs supplemental oxygen when exercising. The other actions are also important, but the first action should be to correct the hypoxemia

The nurse analyzes the results of a patient's arterial blood gases (ABGs). Which finding would require immediate action? a. The bicarbonate level (HCO3-) is 31 mEq/L. b. The arterial oxygen saturation (SaO2) is 92%. c. The partial pressure of CO2 in arterial blood (PaCO2) is 31 mm Hg. d. The partial pressure of oxygen in arterial blood (PaO2) is 59 mm Hg.

ANS: D 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 should intervene immediately to improve the patient's oxygenation

When assessing the respiratory system of an older patient, which finding indicates that the nurse should take immediate action? a. Weak cough effort b. Barrel-shaped chest c. Dry mucous membranes d. Bilateral crackles at lung bases

ANS: D Crackles in the lower half of the lungs indicate that the patient may have an acute problem such as heart failure. The nurse should immediately accomplish further assessments, such as oxygen saturation, and notify the health care provider. A barrel-shaped chest, hyperresonance to percussion, and a weak cough effort are associated with aging. Further evaluation may be needed, but immediate action is not indicated. An older patient has a less forceful cough and fewer and less functional cilia. Mucous membranes tend to be drier

A patient who has a history of chronic obstructive pulmonary disease (COPD) was hospitalized for increasing shortness of breath and chronic hypoxemia (SaO2 levels of 89% to 90%). In planning for discharge, which action by the nurse will be most effective in improving compliance with discharge teaching? a. Start giving the patient discharge teaching on the day of admission. b. Have the patient repeat the instructions immediately after teaching. c. Accomplish the patient teaching just before the scheduled discharge. d. Arrange for the patient's caregiver to be present during the teaching.

ANS: D Hypoxemia interferes with the patient's ability to learn and retain information, so having the patient's caregiver present will increase the likelihood that discharge instructions will be followed. Having the patient repeat the instructions will indicate that the information is understood at the time, but it does not guarantee retention of the information. Because the patient is likely to be distracted just before discharge, giving discharge instructions just before discharge is not ideal. The patient is likely to be anxious and even more hypoxemic than usual on the day of admission, so teaching about discharge should be postponed.

The nurse admits a patient who has a diagnosis of an acute asthma attack. Which statement indicates that the patient may need teaching regarding medication use? a. "I have not had any acute asthma attacks during the last year." b. "I became short of breath an hour before coming to the hospital." c. "I've been taking Tylenol 650 mg every 6 hours for chest-wall pain." d. "I've been using my albuterol inhaler more frequently over the last 4 days."

ANS: D 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. The patient should be taught to contact a health care provider if this occurs. The other data do not indicate any need for additional teaching

The nurse prepares a patient with a left-sided pleural effusion for a thoracentesis. How should the nurse position the patient? a. Supine with the head of the bed elevated 30 degrees b. In a high-Fowler's position with the left arm extended c. On the right side with the left arm extended above the head d. Sitting upright with the arms supported on an over bed table

ANS: D 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. The other positions would increase the work of breathing for the patient and make it more difficult for the health care provider performing the thoracentesis

The laboratory has just called with the arterial blood gas (ABG) results on four patients. Which result is most important for the nurse to report immediately to the health care provider? a. pH 7.34, PaO2 82 mm Hg, PaCO2 40 mm Hg, and O2 sat 97% b. pH 7.35, PaO2 85 mm Hg, PaCO2 45 mm Hg, and O2 sat 95% c. pH 7.46, PaO2 90 mm Hg, PaCO2 32 mm Hg, and O2 sat 98% d. pH 7.31, PaO2 91 mm Hg, PaCO2 50 mm Hg, and O2 sat 96%

ANS: D These ABGs indicate uncompensated respiratory acidosis and should be reported to the health care provider. The other values are normal or close to normal

The nurse palpates the posterior chest while the patient says "99" and notes absent fremitus. Which action should the nurse take next? a. Palpate the anterior chest and observe for barrel chest. b. Encourage the patient to turn, cough, and deep breathe. c. Review the chest x-ray report for evidence of pneumonia. d. Auscultate anterior and posterior breath sounds bilaterally.

ANS: D 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." After noting absent fremitus, the nurse should then auscultate the lungs to assess for the presence or absence of breath sounds. Absent fremitus may be noted with pneumothorax or atelectasis. The vibration is increased in conditions such as pneumonia, lung tumors, thick bronchial secretions, and pleural effusion. Turning, coughing, and deep breathing is an appropriate intervention for atelectasis, but the nurse needs to first assess breath sounds. Fremitus is decreased if the hand is farther from the lung or the lung is hyperinflated (barrel chest).The anterior of the chest is more difficult to palpate for fremitus because of the presence of large muscles and breast tissue

The nurse has just received arterial blood gas (ABG) results on four clients. Which of the following results is considered normal? a. pH 7.32, PaO2 85 mm Hg, PaCO2 55 mm Hg, and O2 saturation 90% b. pH 7.38, PaO2 75 mm Hg, PaCO2 40 mm Hg, and O2 saturation 92% c. pH 7.42, PaO2 80 mm Hg, PaCO2 33 mm Hg, and O2 saturation 98% d. pH 7.52, PaO2 90 mm Hg, PaCO2 30 mm Hg, and O2 saturation 94%

B

The nurse is analyzing the results of a client's arterial blood gases (ABGs). Which of the following findings require the most immediate action? a. The arterial oxygen saturation (SaO2) is 92%. b. The partial pressure of oxygen in arterial blood (PaO2) is 59 mm Hg. c. The partial pressure of CO2 in arterial blood (PaCO2) is 31 mm Hg. d. The bicarbonate level (HCO3 -) is 29 mmol/L.

B

The nurse is auscultating a client's lungs and hears short, high-pitched sounds during exhalation in the lower 1/3 of both lungs. Which of the following information should the nurse document? a. Expiratory crackles at the bases b. Expiratory wheezes in both lungs c. Abnormal lung sounds in the bases of both lungs d. Pleural friction rub in the right and left lower lobes

B

The nurse is caring for a client with a chronic cough who has had a bronchoscopy. Which of the following actions should the nurse include in the nursing care plan after the procedure? a. Elevate the head of the bed to 80-90 degrees. b. Keep the client NPO until the gag reflex returns. c. Place on bed rest for at least 4 hours postbronchoscopy. d. Notify the health care provider about blood-tinged mucus.

B

The nurse is caring for a patient with chronic obstructive pulmonary disorder (COPD) and pneumonia who has an order for arterial blood gases to be drawn. What is the minimum length of time the nurse should plan to hold pressure on the puncture site? a. 2 minutes b. 5 minutes c. 10 minutes d. 15 minutes

B After obtaining blood for an arterial blood gas measurement, the nurse should hold pressure on the puncture site for 5 minutes by the clock to be sure that bleeding has stopped. An artery is an elastic vessel under much higher pressure than veins, and significant blood loss or hematoma formation could occur if the time is insufficient.

After assisting at the bedside with a thoracentesis, the nurse should continue to assess the patient for signs and symptoms of what? a. Bronchospasm b. Pneumothorax c. Pulmonary edema d. Respiratory acidosis

B Because thoracentesis involves the introduction of a catheter into the pleural space, there is a risk of pneumothorax. Thoracentesis does not carry a significant potential for causing bronchospasm, pulmonary edema, or respiratory acidosis.

The nurse is caring for a patient who had abdominal surgery yesterday. Today the patient's lung sounds in the lower lobes are diminished. The nurse knows this could be related to the occurrence of a. pain. b. atelectasis. c. pneumonia. d. pleural effusion.

B Postoperatively, there is an increased risk for atelectasis from anesthesia as well as restricted breathing from pain. Without deep breathing to stretch the alveoli, surfactant secretion to hold the alveoli open is not promoted. Pneumonia will occur later after surgery. 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.

To detect early signs or symptoms of inadequate oxygenation, the nurse would examine the patient for a. dyspnea and hypotension b. apprehension and restlessness c. cyanosis and cool, clammy skin d. increased urine output and diaphoresis

B Rationale: Early symptoms of inadequate oxygenation include unexplained restlessness, apprehension, and irritability.

When auscultating the chest of an older patient in respiratory distress, it is best to a. begin listening at the apices b. begin listening at the lung bases c. begin listening on the anterior chest d. Ask the patient to breathe through the nose with the mouth closed

B Rationale: Normally, auscultation should proceed from the lung apices to the bases so that opposite areas of the chest are compared. If the patient is likely to tire easily or has respiratory distress, start at the bases.

The nurse is interpreting a tuberculin skin test (TST) for a 58-yr-old female patient with end-stage renal disease secondary to diabetes mellitus. Which finding would indicate a positive reaction? a. Acid-fast bacilli cultured at the injection site b. 15-mm area of redness at the TST injection site c. 11-mm area of induration at the TST injection site d. Wheal formed immediately after intradermal injection

C An area of induration 10 mm or larger would be a positive reaction in a person with end-stage renal disease. Reddened, flat areas do not indicate a positive reaction. A wheal appears when the TST is administered that indicates correct administration of the intradermal antigen. Presence of acid-fast bacilli in the sputum indicates active tuberculosis.

The patient is hospitalized with pneumonia. Which diagnostic test should be used to measure the efficiency of gas exchange in the lung and tissue oxygenation? a. Thoracentesis b. Bronchoscopy c. Arterial blood gases d. Pulmonary function tests

C Arterial blood gases are used to assess the efficiency of gas exchange in the lung and tissue oxygenation as is pulse oximetry. Thoracentesis is used to obtain specimens for diagnostic evaluation, remove pleural fluid, or instill medication into the pleural space. Bronchoscopy is used for diagnostic purposes, to obtain biopsy specimens, and to assess changes resulting from treatment. Pulmonary function tests measure lung volumes and airflow to diagnose pulmonary disease, monitor disease progression, evaluate disability, and evaluate response to bronchodilators.

The nurse, when auscultating the lower lungs of the patient, hears these breath sounds. How should the nurse document these sounds? a. Stridor b. Vesicular c. Coarse crackles d. Bronchovesicular

C Coarse crackles are a series of long-duration, discontinuous, low-pitched sounds caused by air passing through an airway intermittently occluded by mucus, an unstable bronchial wall, or a fold of mucosa. Coarse crackles are evident on inspiration and at times expiration. Stridor is a continuous crowing sound of constant pitch from partial obstruction of larynx or trachea. Vesicular sounds are relatively soft, low-pitched, gentle, rustling sounds. They are heard over all lung areas except the major bronchi. Bronchovesicular sounds are normal sounds heard anteriorly over the mainstem bronchi on either side of the sternum and posteriorly between the scapulae with a medium pitch and intensity.

Which patient is exhibiting an early clinical manifestation of hypoxemia? a. A 48-yr-old patient who is intoxicated and acutely disoriented to time and place b. A 67-yr-old patient who has dyspnea while resting in the bed or in a reclining chair c. A 72-yr-old patient who has four new premature ventricular contractions per minute d. A 94-yr-old patient who has renal insufficiency, anemia, and decreased urine output

C Early clinical manifestations of hypoxemia include dysrhythmias (e.g., premature ventricular contractions), unexplained decreased level of consciousness (e.g., disorientation), dyspnea on exertion, and unexplained decreased urine output.

A 67-yr-old male patient had a right total knee replacement 2 days ago. Upon auscultation of the patient's posterior chest, the nurse detects discontinuous, high-pitched breath sounds just before the end of inspiration in the lower portion of both lungs. Which statement most appropriately reflects how the nurse should document the breath sounds? a. "Bibasilar wheezes present on inspiration." b. "Diminished breath sounds in the bases of both lungs." c. "Fine crackles posterior right and left lower lung fields." d. "Expiratory wheezing scattered throughout the lung fields."

C Fine crackles are described as a series of short-duration, discontinuous, high-pitched sounds heard just before the end of inspiration.

The nurse can best determine adequate arterial oxygenation of the blood by assessing a. heart rate b. hemoglobin level c. arterial oxygen partial pressure d. arterial carbon dioxide partial pressure

C Rationale: The ability of the lungs to oxygenate arterial blood adequately is determined by examination of the partial pressure of oxygen in arterial blood (PaO2) and arterial oxygen saturation (SaO2).

The patient is calling the clinic with a cough. What assessment should be made first before the nurse advises the patient? a. Frequency, family history, hematemesis b. Weight loss, activity tolerance, orthopnea c. Cough sound, sputum production, pattern d. Smoking status, medications, residence location

C The sound of the cough, sputum production and description, and the pattern of the cough's occurrence (including acute or chronic) and what its occurrence is related to are the first assessments to be made to determine the severity. Frequency of the cough will not provide a lot of information. Family history can help to determine a genetic cause of the cough. Hematemesis is vomiting blood and not as important as hemoptysis. Smoking is an important risk factor for chronic obstructive pulmonary disease, and lung cancer and may cause a cough. Medications may or may not contribute to a cough as does residence location. Weight loss, activity intolerance, and orthopnea may be related to respiratory or cardiac problems, but are not as important when dealing with a cough.

During the assessment in the emergency department, the nurse is palpating the patient's chest. Which finding is a medical emergency? a. Increased tactile fremitus b. Diminished chest movement c. Tracheal deviation to the left d. Decreased anteroposterior (AP) diameter

C 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.

The nurse is admitting a client to the emergency department who has sudden onset shortness of breath and diagnosed with a possible pulmonary embolus. To confirm the diagnosis, which of the following diagnostic measures should the nurse anticipate? a. Positron emission tomography (PET) scan b. Chest x-ray c. Bronchoscopy d. Spiral computed tomography (CT) scan

D

The nurse is admitting a client who is hypothermic with a O2 saturation of 96%. Which of the following actions should the nurse take next? a. Initiate rewarming of the client. b. Complete a head-to-toe assessment. c. Obtain arterial blood gases (ABGs). d. Place the client on high-flow oxygen.

D

The nurse is admitting a client with acute shortness of breath. Which of the following actions should the nurse take during the initial assessment of the client? a. Complete a full physical examination to determine the systemic effect of the respiratory distress. b. Obtain a comprehensive health history to determine the extent of any prior respiratory problems. c. Delay the physical assessment and ask family members about any history of respiratory problems. d. Perform a respiratory system assessment and ask specific questions about this episode of respiratory distress.

D

The nurse is preparing a client with a right-sided pleural effusion for a thoracentesis. Which of the following positions should the nurse position the client? a. Supine with the head of the bed elevated 45 degrees b. In the Trendelenburg position with both arms extended c. On the left side with the right arm extended above the head d. Sitting upright with the arms supported on an over bed table

D

Which of the following actions should the nurse plan to take for a client who is scheduled for pulmonary function testing (PFT)? a. Explain reasons for NPO status. b. Administer sedative drug before PFT. c. Assess pulse and BP after the procedure. d. Teach deep inhalation and forceful exhalation.

D

Which of the following lung structures has the most generations? a. Segmental bronchi b. Subsegmental bronchi c. Bronchioles d. Alveoli

D

Which of the following pH values is abnormal for a pH when assessing blood results of a mixed venous blood sample? a. 7.31 b. 7.35 c. 7.40 d. 7.42

D

A patient with a recent history of a dry cough has had a chest x-ray that revealed the presence of nodules. In an effort to determine whether the nodules are malignant or benign, what is the primary care provider likely to order? a. Thoracentesis b. Pulmonary angiogram c. CT scan of the patient's chest d. Positron emission tomography (PET)

D 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 CT, a pulmonary angiogram, or thoracentesis.

A patient with a respiratory condition asks, "How does air get into my lungs?" The nurse bases her answer on knowledge that air moves into the lungs because of a. increased CO2 and decreased O2 in the blood b. contraction of the accessory abdominal muscles c. stimulation of the respiratory muscles by the chemoreceptors d. decrease in intrathoracic pressure relative to pressure at the airway

D Rationale: During inspiration, the diaphragm contracts, moves downward, and increases intrathoracic volume. At the same time, the external intercostal muscles and scalene muscles contract, increasing the lateral and anteroposterior dimension of the chest. This causes the size of the thoracic cavity to increase and intrathoracic pressure to decrease, so air is pulled into the lungs.

Which assessment finding of the respiratory system does the nurse interpret as abnormal? a. Inspiratory chest expansion of 1 inch b. Symmetric chest expansion and contraction c. Resonance (to percussion) over the lung bases d. Bronchial breath sounds in the lower lung fields

D Rationale: Vesicular breath sounds are most commonly auscultated over the peripheral lung fields. Bronchial or bronchovesicular sounds heard in the peripheral lung fields would be abnormal.

After swallowing, a 73-yr-old patient is coughing and has a wet voice. What changes of aging could be contributing to this abnormal finding? a. Decreased response to hypercapnia b. Decreased number of functional alveoli c. Increased calcification of costal cartilage d. Decreased respiratory defense mechanisms

D These manifestations are associated with aspiration, which more easily occur in the right lung as the right mainstem bronchus is shorter, wider, and straighter than the left mainstem bronchus. Aspiration occurs more easily in the older patient related to decreased respiratory defense mechanisms (e.g., decreases in immunity, ciliary function, cough force, sensation in pharynx). Changes of aging include a decreased response to hypercapnia, decreased number of functional alveoli, and increased calcification of costal cartilage, but these do not increase the risk of aspiration.

When the patient is experiencing metabolic acidosis secondary to type 1 diabetes mellitus, what physiologic response should the nurse expect to assess in the patient? a. Vomiting b. Increased urination c. Decreased heart rate d. Increased respiratory rate

D When a patient with type 1 diabetes has hyperglycemia and ketonemia causing metabolic acidosis, the physiologic response is to increase the respiratory rate and tidal volume to blow off the excess CO2. Vomiting and increased urination may occur with hyperglycemia, but not as physiologic responses to metabolic acidosis. The heart rate will increase.