Med-Surg: Respiratory Assessment/Alteration

The nurse knows that fibrosis, edema, decreased surfactant, and atelectasis can all affect lung compliance. True/False?

True

Your sister says to you, "Well, I want to put Grandma in West Parks Nursing Home because they won't poke on her like those other Homes do." You ask your sister (you are a nurse), "What do you mean when you say: they won't poke on Grandma like other places will?" Your sister says, "Well, they won't make her get the flu shot and that TB shot thing, and you know-you know how she hates getting stuck by needles." What is the most appropriate thing you can say to your sister about Mantoux TST test?

answer: "Grandma can refuse the flu vaccine because that is her right as the patient; however in order for Grandma to reside in any long-term care facility in the US, she would be required to receive the Mantoux TST test upon admission for TB. We should talk with Grandma about this and go from there."

True/False: Your patient comes in after suspecting she has the flu. C&S tests confirm she does. She proceeds to tell you that she had been running a fever for about 3 days but now she isn't-you confirm after taking her V/S this. She says to you, "At least no one in my household are at risk now that I'm not running a fever." You agree with her and proceed with your assessment because you know that influenza is only contagious while a person has a fever, which lasts usually 3 days.

answer: False rationale: People are contagious for 1 day BEFORE they feel ill and continue to be contagious for up to 5-7 days AFTER they get sick(with or without fever).

True/False: A positive TST result is evidence that a TB infection has existed at some time somewhere in the body and indicates active disease.

answer: False rationale: a positive TST result does indicate infection existed somewhere HOWEVER DOEN NOT NECESSARILY INDICATE ACTIVE DISEASE.

Because alveolar walls contain less capallaries as a person ages; you now know that in the elderly this causes what to change?

answer: Gas exchange. rationale: gas exchange DECREASES when there are less capillaries in the alveolar walls.

A client comes to the doctor's office describing shortness of breath and strange breath sounds when inhaling deeply. Upon auscultation of the lung fields, sibilant wheezes are noted. Which of the following statements by the nurse most correct? a. "Wheezes result from air passing through narrowed passages." b. "Wheezes result from air escaping through a pneumothorax." c. "Wheezes result from air collecting in the pleural cavity." d. "Wheezes result from air between visceral and parietal pleurae."

answer: a ratioanle: wheezes may be sibilant (hissing/whistling) or sonorous (full and deep). Sibilant wheezes (formerly called wheezes) are continuous musical sounds that can be heard during inspiration and expiration; and result from air passing through narrowed or partially obstructed air passages and are heard in clients with increased secretions.

A nurse identified Ineffective Airway Clearance related to a malignant mass in the client's airway. Which of the following interventions has the highest priority? a. elevate the client's head of the bed b. encourage the client to deep breathe and cough every 2 hours c. place a nasal cannula with 2L of oxygen d. provide emergency tracheostomy equipment at the bedside

answer: a rationale: Maintaining the airway is the highest priority.

When caring for a client having a lung scan, which of the following nursing interventions is most important during the procedure? a. reassure the client about the amount of radiation from the procedure. b. coach the client to hold his or her breath at times during the procedure c.administer sedative or narcotic as per orders before the procedure d. aid the client to rest arms and head on a pillow during the procedure.

answer: a rationale: the client must receive adequate explanations before the procedure to reduce anxiety. The nurse must reassure the client that the amount of radiation from this procedure is less than that used during a chest x-ray.

The physician orders arterial blood gases (ABGs) to determine various factors related to blood oxygenation on a patient who presents in respiratory distress. What site can ABGs be obtained from? a. a puncture in the raidal artery b. the trachea and bronchi c. a swab from the nasopharynx d. an intravenous catheter in the arm vein

answer: a rationale: ABGs determine the blood's ph; oxygen-carrying capacity; and levels of: oxygen, carbon dioxide, and bicarbonate ion. Blood gas samples are obtained through an arterial puncture at the radial, brachial, or femoral artery.

What sounds would the nurse expect to hear upon listening to a patient with pneumonia? Select all that apply. a)crackles b)rhonchi c)wheezing d) diminished breath sounds

answer: a, c, d

The nurse expects to hear what lung sounds from a patient with pleural effusion? Select all that apply. a)friction rubs b)crackling c)wheezing d)diminished/absent breathe sounds

answer: a, d

You are caring for 3 different clients. Client A is one day postop for an emergency abdominal surgical procedure r/t getting into a car accident two nights ago and will be bedridden for several days, and you notice in his chart that he has a hx of DVT; Client B is a 30 year old woman taking estrogen replacement therapy and smokes ~pack/day. She was admitted tonight for a right leg fx-r/t an extreme hiking trip for survivors in the Alps (she proudly tells you how she had managed to go for three days without eating or drinking). Client C is found ambulating in the hall with her husband after being admitted last night for a broken wrist-she proudly tells you in passing she can't stand just lying around in bed. You know that which patient(s) at risk for having developing a pulmonary embolism, select all. a)none of them b)Client A c)Client B d)Client C

answer: a,b rationale: any abdominal/leg issue/surgery raises the risk of developing a DVT, also a client needs to change positions/ambulate, dont' cross legs, keep hydrated, wear support hose, avoid constricting clothing, do leg exercises, stop smoking; history of of DVTs put you at risk, taking estrogen replacement therapy puts you at risk.

A client was seen in the emergency rom with severe epistaxis. After the physician places a nasal packing, the bleeding is controlled. What should the nurse include as part of the discharge instructions? Select all that apply. a. call physician if bleeding persists or becomes worse b. continue taking baby aspirin as ordered c. do not blow the nose d. keep nasal packing in place until seen for follow-up appointment e. swallow any oozing blood to avoid coughing

answer: a,c,d rationale: do not swallow blood; spit out any blood oozing from the area. Do not blow the nose. If blood has been swallowed, the client may see diarrhea and black, tarry stools for a few days; do not attempt to remove nasal packing or to cut the string anchoring the packing; do not use aspirin or ibuprofen products until bleeding is controlled; and notify the physician if bleeding persists or if any respiratory problems develop.

The nurse is giving instructions to a client having pulmonary angiography. Which of the following statements is the best evidence that the client understands the nurse's instructions about what will take place during the diagnostic procedure? Select all that apply. a. "I may feel some pressure at the site." b. "I may have bleeding at the site following the procedure." c. "I will not be allowed to cough after the procedure." d. "I will sense a warm, flushed feeling and an urge to cough when the dye is injected."

answer: a,d rationale: during pulmonary angiograpy, the nurse obtains data about the client's level of anxiety and knowledge of the procedure. The nurse provides explanations and reinforces the client's understanding. The client will experience a feeling of pressure on catheter insertion. When the contrast medium is infused, the client will sense a warm, flushed feeling and an urge to cough.

A nurse needs to obtain a sputum specimen from an adult client. Which nursing action will best facilitate obtaining the specimen? a. ask the client to spit into the collection container b. have the client take deep breaths c. restrict the client's fluids d. wait until after the client has eaten to get the specimen.

answer: b rationale: collecting a sputum specimen have the client rinse their mouth with tap water; instruct the client to take several deep breaths, cough forcefully, and expectorate into the container.

While conducting the physical examination during assessment of the respiratory system, which of the following would describe lung sounds produced by air movement through the trachea and are loud with long expiration? a. bronchovesicular sounds b. bronchial sounds c. sonorous wheezes d. vesicular sounds

answer: b rationale: normal bronchial lung sounds are auscultated over the trachea and are loud with long expiration.

An elderly client is brought to the emergency department. Vital signs are: Temp: 102 degrees F; P: 88; R: 32; BP: 160/86. Upon physical examination, the client is having difficulty breathing. Which of the following would be most appropriate for the nurse to do next? a. Instruct the client to take slow, deep breaths b. suction the client's pharynx of secretions c. apply a pulse oximeter to the client's finger d. help the client perform postural drainage

answer: b rationale: the nurse will auscultates lung sounds and monitors the client for signs of respiratory difficulty. They check oxygenation status with pulse oximetry and monitors arterial blood gases (ABGs).

Movement of air into and out of the lungs sufficient to maintain normal arterial oxygen and carbon dioxide tensions is termed what? a. perfusion b. ventilation c. diffusion d. inspiration

answer: b rationale: ventilation is the actual movement of air in and out of the respiratory tract. This process requires a patent airway and intact and functioning respiratory muscles.

What type of breath sounds would the nurse expect to find in a patient with atelectasis? Select all that apply. a)wheezing without auscultation b)crackling in affected areas c)absent breath sounds d)rhonchi

answer: b, c rationale: may find upon auscultaion over affected areas: crackling and usually breath sounds are absent

The nurse would expect which sound while listening to a acute bronchitis patient? a) fine crackles b) moist crackles upon inspiratory and wheezing c) wheezing d) rales

answer: b,c

When this listening to a patient with a pulmonary embolism, the nurse knows she might hear any of these breathe sounds except... a) egophony (E sounds like A through stethoscope) b) dullness, decreased breathe sounds c) bronchovesicular sounds d) wheezing

answer: c rationale: bronchovesciular sounds would be heard in person with normal breathe sounds.

The nurse is providing postoperative care for a client who has undergone tonsillectomy. In which position will the nurse place the head of the bed when the client is fully awake? a. flat with the head elevated on a pillow b. slightly raised at a 15 degree angle c. raised at a 45 degree angle d. raised at a 90 degree sitting position

answer: c rationale: elevate head of bed to semi-fowler's position (45 degrees) when the client is fully awake. This position decreases surgical edema and increases lung expansion.

A nurse is auscultating the lung sounds of a client who came to the clinic for a physical exam. There is not any history of lung disease. What should the nurse expect to hear? a. adventitious breath sounds b. bronchial breath sounds c. bronchovesicular breath sounds d. vesicular breath sounds

answer: c rationale: the nurse auscultates breath sounds from side to side, moving from the upper to the lower chest. They listen anteriorly, laterally, and posteriorly. Normal breath sounds include bronchovesicular sounds.

A client with moderately controlled asthma needs to use a peak flow meterl Which of the following statements by the nurse best explains the purpose of a peak flow meter? a) a peak flow meter measures the amount of forced inspiration b) a peak flow meter measures the depth of forced inhalation c)a peak flow meter measures the highest flow with forced expiration d)a peak flow meter measures the residual volume after exhalation

answer: c rationale: the peak flow meter measures the peak expiratory flow rate (PEFR) and is used by the client to assess the effectiveness of medication or breathing status.

The LPN notes that her patient is 2 days postop from ICU for thoracic surgery; the care plan reads: Impaired Gas Exchange r/t decreased lung expansion, impaired lung function, and surgical procedure. Which interventions are of primary importance for the care of the client? Select all the apply. a) assess the client's dressings and incisions for increased drainage b)monitor client's temperature at least every 4 hours c) remind the client to deep breathe and cough at least every 2 hours d)reposition the client so that the head is elevated 30-40 degrees e) 30 minutes after giving pain meds ask client to rate pain on a scale of 1-10.

answer: c, d

What breathe sounds would the nursing student expect to hear with a patient with ARDS. Select all the apply. a)egophony b)dullness, and decreased breathe sounds c)crackles d)wheezing

answer: c,d

With a patient being observed overnight in the hospital for broken ribs of these, what is she monitoring for? a)anxiety b)fatigue c)increased pain d)resp distress e)infection

answer: c,d,e

A client is seen in a clinic for possible laryngeal cancer. In reviewing the client's record, the nurse will most likely see which of the following early complaints expressed by the client? a. difficulty swallowing hot liquids b. enlarged lymph nodes in the neck c. generalized discomfort in the neck d. persistent hoarseness for the last month

answer: d rationale: early signs and symptoms are persistent and progressive hoarseness (longer than 2 weeks) is usually the earliest symptom, and is usually ignored by the client.

The nurse is caring for a client with TB. A sputum sample is ordered for the next 3 consecutive days. What time is it best for the nurse to schedule the collection of sputum? a) at bedtime b) before a meal c) following breakfast d) upon arising in the morning

answer: d rationale: most clients find that it is easier to raise sputum when they first awaken; and may be necessary to collect specimens on several consecutive days.

Of the following instructions, which is most important for the nurse to teach the client to help loosen secretions and increase comfort during medical treatment for sinusitis? a. blow the nose frequently b. elevate the head of the bed by 45 degrees c. engage in normal activity d. increase fluid intake

answer: d rationale: the nurse needs to inform the client receiving medical treatment for sinusitis that use of mouthwashes and humidification as well as increased fluid intake may loosen secretions and increase comfort; the nurse should also instruct the client to take nasal decongestants and antihistamines as ordered.

A nurse is palpating her patients forearm, the location where she had made a pronounced wheal 48 hours ago. She finds erythema (redness) without induration. Is this significant or not significant?

answer: not significant rationale: if erythema is without induration, it is not significant; if erythema IS present with induration, read the induration only,; interpret test results as follows: 0-4 mm=induration considered not significant & no follow-up needed; if greater than 5 mm=induration may be significant in clients what are considered to be at risk.

The nurse would expect which sound while listening to a lung cancer patient? a)wheezing b)fine crackles c)absent breathe sounds d)stridor

answer: stridor