EAQ-Content Area-MedSur-Respiratory
While assessing the medical reports of a client with upper respiratory tract infections, the nurse notices that there are alterations in the platelet count. The client has a history of recent nasal surgery. Which clinical condition does the nurse suspect? A. Epistaxis B. Rhinosinusitis C. Allergic rhinitis D. Acute pharyngitis
ANSWER: A RATIONALE: Epistaxis or nosebleeds may alterplatelet counts. Epistaxis may be observed in clients with upper respiratory tract infections, overuse of decongestant nasal sprays, or nasal surgery. Rhinosinusitis is the concurrent inflammation of the nasal mucosa. Allergic rhinitis is the reaction of the nasal mucosa to a specific allergen. Acute pharyngitis is an acute inflammation of the pharyngeal walls caused by viral or bacterial infections.
A client is discharged from the hospital after receiving a lung transplant. Which medical device should the client use to monitor his or her lung function at home? a. Oximetry b. Spirometry c. Capnography d. Ventilation-perfusion
ANSWER: B RATIONALE: A spirometer is a hand-held device that can be used at home. A client blows forcefully and quickly into the device after taking a deep breath. This device is used to diagnose early lung transplant rejections or infections and helps to monitor lung function. Oximetry is used for the intermittent monitoring of arterial or venous oxygen saturation. Capnography helps to assess the level of CO2 in exhaled air; this device graphically displays the amount of partial pressure of CO2. Ventilation-perfusion is used to assess the ventilation and perfusion of the lungs.
A nurse auscultates a client's lungs and hears a fine crackling sound in the left lower lung during respiration. The nurse charts, "crackles and rhonchi in the left lower lung." What does this documentation represent? A. A nursing diagnosis B. An inaccurate interpretation C. A correct nursing assessment D. An accurate conclusion if crepitus was ruled out
ANSWER: B RATIONALE: Rhonchi [1] [2] are coarse sounds heard over the larger airways; including rhonchi in the record makes the documentation inaccurate. Crackles and rhonchi are clinical indicators, not a nursing diagnosis. It is incorrect to use the term rhonchi to refer to crackling sounds in the lower lung. Crepitus, which indicates subcutaneous emphysema, is unrelated to auscultated breath sounds.
After resection of a lower lobe of the lung, a client has excessive respiratory secretions. Which independent nursing action should the nurse implement? A. Postural drainage B. Turning and positioning C. Administration of an expectorant D. Percussion and vibration techniques
ANSWER: B RATIONALE: Turning and positioning does not require a healthcare provider's prescription and is an independent action. Postural drainage, administration of an expectorant, and percussion and vibration techniques are dependent nursing functions that require a healthcare provider's prescription.
What order would the nurse follow for the assessment of the pharynx in a client with a respiratory disorder? A. Inspect the neck symmetry. B. Inspect the mouth. C. Palpate the lymph nodes. D. Observe the rise and fall of the soft palate. E. Assess the symmetry of enlarged tonsils, if present.
ANSWER: B-D-E-A-C RATIONALE: The assessment of the pharynx begins with an inspection of the mouth. By using a tongue depressor, the posterior pharynx and the rise and fall of the soft palate are observed. The next step is to assess for edema or ulceration and the symmetry of the enlarged tonsils. The neck is inspected for symmetry, alignment, masses, swelling, bruises, and the use of accessory neck muscles in breathing. The last step is to palpate the lymph nodes for size, shape, mobility with palpation, consistency, and tenderness.
A client with emphysema is admitted to the hospital with pneumonia. On the third hospital day, the client complains of a sharp pain on the right side of the chest. The nurse suspects a pneumothorax. What breath sound is most likely to be present when the nurse assesses the client's right side? A. Cracking B. Wheezing C. Decreased sounds D. Adventitious sounds
ANSWER: C RATIONALE: Because the affected lung will not expand, aeration of the lung is not complete, and breath sounds are diminished. Crackling sounds occur with pulmonary edema, not with a pneumothorax; with a pneumothorax there is no air in the alveoli to produce crackles. Wheezing sounds occur with asthma, not with a pneumothorax. "Adventitious sounds" is a broad term that includes all abnormal breath sounds; it is not specific to pneumothorax.
Besides providing reassurance, what should nursing interventions for a client who is hyperventilating be focused on? A. Administering oxygen B. Using an incentive spirometer C. Having the client breathe into a paper bag D. Administering an IV containing bicarbonate ions
ANSWER: C RATIONALE: Reassurance decreases anxiety and slows respirations; the bag is used so that exhaled carbon dioxide can be rebreathed to resolve respiratory alkalosis and return the client to an acid-base balance. Administering oxygen is not necessary because there is no evidence of hypoxia. Using an incentive spirometer is used to prevent atelectasis. The client is already alkalotic; bicarbonate ions will increase the problem.
After a thoracentesis for pleural effusion, a client returns to the outpatient clinic for a follow-up visit. The nurse suspects a recurrence of pleural effusion when the client makes which statement? A. "Lately I can only breathe well if I sit up." B. "During the night I sometimes get the chills." C. "I get a sharp, stabbing pain when I take a deep breath." D. "I'm coughing up larger amounts of thicker mucus for the last several days."
ANSWER: C RATIONALE: Tension is placed on the pleura at the height of inspiration and causes pain. The response "Lately I can only breathe well if I sit up" is typical of heart failure. The response "During the night I sometimes get the chills" may indicate a pulmonary infection. The response "I'm coughing up larger amounts of thicker mucus for the last several days" may indicate a pulmonary infection.
A nurse is caring for a client with pulmonary tuberculosis. What must the nurse determine before discontinuing airborne precautions? A. Client no longer is infected B. Tuberculin skin test is negative. C. Sputum is free of acid-fast bacteria. D. Client's temperature has returned to normal.
ANSWER: C RATIONALE: The absence of bacteria in the sputum indicates that the disease can no longer be spread by the airborne route. Treatment is over an extended period; eventually the client may not have an active disease, but still remains infected. Once an individual has been infected, the test will always be positive. The client's temperature returning to normal is not evidence that the disease cannot be transmitted.
A client with chronic obstructive pulmonary disease (COPD) has a blood pH of 7.25 and PCO2 of 60 mm Hg. These blood gases require nursing attention because they indicate which condition? a. Metabolic Acidosis b. Metabolic Alkalosis c. Respiratory Acidosis d. Respiratory Alkalosis
ANSWER: C RATIONALE: The normal blood pH range is 7.35 to 7.45; therefore, a blood pH of 7.25 indicates acidosis. The parameter for respiratory function is CO2 and the acceptable range of arterial PCO2 is 35 to 45 mm Hg; therefore, 60 mm Hg is elevated, resulting in respiratory acidosis. HCO3 is the parameter for metabolic functions. A pH of 7.25 is acidic, indicating acidosis and not alkalosis.
A client is admitted with suspected atelectasis. Which clinical manifestation does the nurse expect to identify when assessing this client? A. Slow, deep respirations B. Normal oral temperature C. Dry, unproductive cough D. Diminished breath sounds
ANSWER: D RATIONALE: Because atelectasis [1] [2] involves collapsing of alveoli distal to the bronchioles, breath sounds are diminished in the lower lobes. The client will have rapid, shallow respirations to compensate for poor gas exchange. Atelectasis results in an elevated temperature. Atelectasis results in a loose, productive cough.
Which respiratory measurement is useful in differentiating between obstructive and restrictive pulmonary dysfunction? a. Peak expiratory flow rate b. Forced vital capacity c. Forced mid-expiratory flow rate d. Forced expiratory volume/forced vital capacity ratio
ANSWER: D RATIONALE: Forced expiratory volume/forced vital capacity ratio is useful in differentiating between obstructive and restrictive pulmonary dysfunction. Peak expiratory flow rate aids in monitoring bronchoconstriction in asthma. Forced vital capacity is the amount of air that can be quickly and forcefully exhaled after maximum inspiration. Forced mid-expiratory flow rate is an early indicator of disease of the small airways.
A nurse is caring for a client on mechanical ventilation. The nurse should monitor for which sign of hyperventilation? A. Tetany B. Hypercapnia C. Metabolic acidosis D. Respiratory alkalosis
ANSWER: D RATIONALE: Increased rate and depth of breathing result in excessive elimination of CO2, and respiratory alkalosis [1] [2] can result. Tetany is associated with hypocalcemia. With hyperventilation, CO2 levels will be decreased (hypocapnia), not elevated. Metabolic acidosis results from excess hydrogen ions caused by a metabolic problem, not a respiratory problem.
A client reports left-sided chest pain after playing racquetball. The client is hospitalized and diagnosed with left pneumothorax. When assessing the client's left chest area, the nurse expects to identify which finding? A. Dull sound on percussion B. Vocal fremitus on palpation C. Rales with rhonchi on auscultation D. Absence of breath sounds on auscultation
ANSWER: D RATIONALE: The left lung is collapsed; therefore, there are no breath sounds. A tympanic, not a dull, sound will be heard with a pneumothorax [1] [2]. There is no vocal fremitus because there is no airflow into the left lung as a result of the pneumothorax. Rales with rhonchi will not be heard because there is no airflow into the left lung as a result of the pneumothorax.
A client with a history of rheumatic fever and a heart murmur reports gaining weight in spite of nausea and anorexia. The client also reports shortness of breath several times each day and when performing minor tasks. Which additional information should the nurse obtain? a. Retrospective 24-hour calorie count b. Elimination pattern during the last 30 days c. Complete gynecological and sexual history d. Presence of a cough and pulmonary secretions
ANSWER: D RATIONALE: The presence of a cough and pulmonary secretions, in addition to a history of rheumatic fever, requires an assessment for other cardiopulmonary problems and fluid overload. Anorexia and weight gain do not indicate a nutritional problem but a fluid balance problem. Loss of appetite in conjunction with shortness of breath and the history of rheumatic fever makes gastrointestinal (elimination) symptoms secondary in importance. There is no reason to investigate the gynecological and sexual history in relation to the current problem.