Chapter 26 - Nursing Management: Respiratory System (7th edition)

A patient with COPD has a "barrel chest." The nurse would expect the chest x-ray report to indicate that there is a. overinflation of the alveoli. b. consolidation of lung tissue. c. fluid in the alveoli. d. air in the pleural space.

Correct Answer: A Rationale: A barrel chest results from lung hyperinflation and is a common finding in patients with COPD. Consolidation, fluid, and air in the pleural space all would indicate that intervention is needed. Cognitive Level: Application Text Reference: pp. 511, 521 Nursing Process: Assessment NCLEX: Physiological Integrity

In analyzing the results of a patient's blood gas analysis, the nurse will be most concerned about an a. arterial oxygen tension (PaO2) of 60 mm Hg. b. arterial oxygen saturation (SaO2) of 91%. c. arterial carbon dioxide (PaCO2) of 47 mm Hg. d. arterial bicarbonate level (HCO3) of 27 mEq/L.

Correct Answer: A Rationale: 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. Cognitive Level: Analysis Text Reference: p. 513 Nursing Process: Assessment NCLEX: Physiological Integrity

An 80-year-old patient breathing room air has an ABG analysis. The nurse interprets which results as normal? a. pH 7.38, arterial carbon dioxide (PaO2) 82 mm Hg, PaCO2 40 mm Hg, and O2 sat 92% b. pH 7.32, PaO2 85 mm Hg, PaCO2 55 mm Hg, and O2 sat 90% c. pH 7.48, PaO2 90 mm Hg, PaCO2 31 mm Hg, and O2 sat 98% d. pH 7.52, PaO2 91 mm Hg, PaCO2 42 mm Hg, and O2 sat 94%

Correct Answer: A Rationale: All the values in this answer are correct. The answer beginning "pH 7.32, PaO2 85 mm Hg" shows respiratory acidosis. The answer beginning "pH 7.48, PaO2 90 mm Hg" indicates respiratory alkalosis, and the answer beginning "pH 7.52, PaO2 91 mm Hg" shows metabolic alkalosis. Cognitive Level: Application Text Reference: p. 514 Nursing Process: Implementation NCLEX: Physiological Integrity

A patient with COPD is admitted to the hospital with dyspnea and a cough producing yellow sputum. When palpating the patient's thorax, the nurse will expect to find that chest expansion is a. diminished. b. asymmetric. c. normal. d. increased.

Correct Answer: A Rationale: Chronic lung hyperinflation, such as occurs in COPD, decreases expansion of the lungs with inspiration. Lung expansion is usually symmetrical with emphysema. Cognitive Level: Application Text Reference: pp. 524, 526 Nursing Process: Assessment NCLEX: Physiological Integrity

A patient is admitted with a metabolic acidosis of unknown origin. Based on this diagnosis, the nurse would expect the patient to have a. Kussmaul's respirations. b. slow, shallow respirations. c. a low oxygen saturation (SpO2). d. a decrease in PVO2.

Correct Answer: A Rationale: Kussmaul's (deep and rapid) respirations are a compensatory mechanism for metabolic acidosis. Slow, shallow respirations, a low oxygen saturation rate, and a decrease in PVO2 would not be caused by acidosis. Cognitive Level: Analysis Text Reference: p. 524 Nursing Process: Assessment NCLEX: Physiological Integrity

While caring for a patient with respiratory disease, the nurse observes that the patient's SpO2 drops from 94% to 85% when the patient ambulates in the hall. The nurse determines that a. supplemental oxygen should be used whenever the patient exercises. b. arterial blood gas analysis should be done to verify the patient's SpO2. c. the response is normal and the patient should continue at this activity level. d. the patient activity should be limited until the disease process is resolved.

Correct Answer: A Rationale: The drop in SpO2 to 85% indicates that the patient is hypoxemic and needs supplemental oxygen when exercising. ABG measurements are unnecessary and would increase patient discomfort and expense. The patient will need to continue to ambulate to avoid the many complications of immobility. Cognitive Level: Application Text Reference: p. 515 Nursing Process: Evaluation NCLEX: Physiological Integrity

The nurse is admitting a patient who has a diagnosis of an acute asthma attack. Which information obtained by the nurse indicates that the patient may need teaching regarding medication use? a. The patient has been using the albuterol (Proventil) inhaler more frequently over the last 4 days. b. The patient became very short of breath an hour before coming to the hospital. c. The patient has been taking acetaminophen (Tylenol) 650 mg every 6 hours for chest-wall pain. d. The patient says there have been no acute asthma attacks during the last year.

Correct Answer: A Rationale: 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. Cognitive Level: Application Text Reference: p. 517 Nursing Process: Assessment NCLEX: Physiological Integrity

When performing an assessment of the patient's respiratory system, the nurse uses the following illustrated technique to evaluate a. chest expansion. b. tactile fremitus. c. accessory muscle use. d. diaphragmatic excursion.

Correct Answer: A Rationale: When assessing chest expansion on the posterior chest, the nurse will place the hands at the level of the 10th rib, position the thumbs until they meet over the spine, and have the patient breathe deeply. Tactile fremitus is assessed by having the patient repeat a word or phrase such as "ninety-nine" while the nurse uses the palms of the hands to assess for vibration. Accessory muscle use and anterior-posterior diameter are assessed during inspection of the chest and do not require palpation. Cognitive Level: Comprehension Text Reference: p. 522 Nursing Process: Assessment NCLEX: Physiological Integrity

A hypothermic patient is admitted to the emergency department, and pulse oximetry (SpO2) indicates that the O2 saturation is 95%. Which action should the nurse take next? a. Complete a head-to-toe assessment. b. Place the patient on high-flow oxygen. c. Start rewarming the patient. d. Obtain arterial blood gases (ABG).

Correct Answer: B Rationale: 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 until the patient is normothermic. The other actions are also appropriate, but the initial action should be to administer oxygen. Cognitive Level: Analysis Text Reference: pp. 513, 515 Nursing Process: Assessment NCLEX: Physiological Integrity

A patient with chronic hypoxemia (SaO2 levels of 89%-90%) caused by COPD has just been admitted with increasing shortness of breath. In planning for discharge, which of these actions by the nurse will be most effective in improving compliance with discharge teaching? a. Have the patient repeat the instructions immediately after the teaching. b. Arrange for the patient's spouse to be present during the teaching. c. Accomplish the patient teaching just before the scheduled discharge. d. Start giving the patient discharge teaching on the day of admission.

Correct Answer: B Rationale: Hypoxemia interferes with the patient's ability to learn and retain information, so having the patient's spouse 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. Cognitive Level: Application Text Reference: p. 520 Nursing Process: Planning NCLEX: Physiological Integrity

A patient who has a 30-pack-year history of smoking asks the nurse, "How does smoking really harm my lungs?" The nurse's response will be based on the effect of smoking on a. cough and gag reflexes. b. mucociliary clearance. c. reflex bronchoconstriction. d. the filtration of inspired air.

Correct Answer: B Rationale: Smoking decreases ciliary action and the ability of the mucociliary clearance system to trap particles and move them out of the lung. The cough/gag reflexes, reflex bronchoconstriction, and filtration of air by the nasal hairs are not affected by smoking. Cognitive Level: Comprehension Text Reference: p. 516 Nursing Process: Assessment NCLEX: Physiological Integrity

A patient is admitted to the emergency department complaining of sudden onset shortness of breath and diagnosed with a possible pulmonary embolus. To confirm the diagnosis, the nurse will anticipate preparing the patient for a a. chest x-ray. b. spiral CT scan. c. bronchoscopy. d. PET scan.

Correct Answer: B Rationale: Spiral CT scans are the most commonly used test to diagnose pulmonary emboli. A chest x-ray may be ordered but will not be diagnostic for a pulmonary embolus. Bronchoscopy is used to inspect for changes in the bronchial tree, not to assess for vascular changes. PET scans are most useful in determining the presence of malignancy. Cognitive Level: Application Text Reference: p. 526 Nursing Process: Planning NCLEX: Physiological Integrity

A patient who is restricted to bed rest asks the nurse the purpose of the deep breathing exercises. Which reply by the nurse is correct? a. Deep breathing enhances ciliary activity and promotes bronchial clearance. b. Deep breathing stretches the alveoli and stimulates the production of surfactant. c. Deep breathing increases the diaphragmatic strength improving respiratory effort. d. Deep breathing stimulates the Hering-Breuer reflex to increase respiratory rate.

Correct Answer: B Rationale: Taking deep breaths or sighs usually occurs every five to six breaths and (through alveolar stretching and improved surfactant production) decreases the risk for atelectasis. Ciliary activity, diaphragmatic strength, and the respiratory rate are not changed by deep breathing. Cognitive Level: Application Text Reference: p. 511 Nursing Process: Implementation NCLEX: Physiological Integrity

When auscultating a patient's chest while the patient takes a deep breath, the nurse hears loud, high-pitched, "blowing" sounds at both lung bases. The nurse will document these as a. adventitious sounds. b. abnormal sounds. c. vesicular sounds. d. normal sounds.

Correct Answer: B Rationale: The description indicates that the nurse hears bronchial breath sounds that are abnormal when heard at the lung base. Adventitious sounds are crackles, wheezes, rhonchi, and friction rubs. Vesicular sounds are low-pitched, soft sounds heard over all lung areas except the major bronchi. Cognitive Level: Application Text Reference: p. 524 Nursing Process: Assessment NCLEX: Physiological Integrity

The health care provider performs a thoracentesis on a patient with a right pleural effusion. In preparing the patient for the procedure, the nurse positions the patient a. supine with the head of the bed elevated 45 degrees. b. sitting upright with the arms supported on an overbed table. c. on the left side with the right arm extended above the head. d. in Trendelenburg's position with both arms extended.

Correct Answer: B Rationale: 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. Cognitive Level: Application Text Reference: pp. 528, 530 Nursing Process: Implementation NCLEX: Physiological Integrity

On auscultation of a patient's lungs, the nurse hears short, high-pitched sounds just before the end of inspiration in the right and left lower lobes. The nurse records this finding as a. abnormal lung sounds in the bases of both lungs. b. inspiratory wheezes in both lungs. c. crackles in the right and left lower lobes. d. pleural friction rub in the right and left lower lobes.

Correct Answer: B Rationale: Wheezes are high-pitched sounds; in this case, they are heard during the inspiratory phase of the respiratory cycle. Abnormal breath sounds are bronchial or bronchovesicular sounds heard in the peripheral lung fields. Crackles are low-pitched, "bubbling' sounds. Pleural friction rubs are grating sounds that are usually heard during both inspiration and expiration. Cognitive Level: Comprehension Text Reference: p. 525 Nursing Process: Assessment NCLEX: Physiological Integrity

A patient with a chronic cough with blood-tinged sputum undergoes a bronchoscopy. Following the bronchoscopy, the nurse should a. check vital signs every 15 minutes for 2 hours. b. place the patient on bed rest for at least 4 hours. c. keep the patient NPO until the gag reflex returns. d. elevate the head of the bed to 80 to 90 degrees.

Correct Answer: C Rationale: 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. Vital signs are monitored immediately after the procedure but should not need to be obtained every 15 minutes for 2 hours. 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. Cognitive Level: Application Text Reference: p. 528 Nursing Process: Implementation NCLEX: Physiological Integrity

A patient is scheduled for a spiral CT scan to rule out a pulmonary embolus. Which information obtained by the nurse is most important to communicate to the health care provider before the examination? a. The apical pulse is irregular. b. The oxygen saturation is 93%. c. The patient is allergic to shellfish. d. The patient is very tachypneic.

Correct Answer: C Rationale: Because the contrast solution is iodine-based, the patient may need to have the CT scan without contrast or be premedicated before contrast injection. The irregular pulse, oxygen saturation, and tachypnea all need further assessment or intervention but are not unusual for a patient with a possible pulmonary embolus. Cognitive Level: Application Text Reference: p. 527 Nursing Process: Implementation NCLEX: Physiological Integrity

When assessing the respiratory system of a 78-year-old patient, which of these data indicate that the nurse should take immediate action? a. The chest appears barrel shaped. b. The patient has a weak cough effort. c. Crackles are audible in the lower two thirds of the posterior chest. d. Hyperresonance is present across both sides of the chest.

Correct Answer: C Rationale: Crackles in the lower two thirds 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. Cognitive Level: Application Text Reference: p. 524 Nursing Process: Assessment NCLEX: Physiological Integrity

The nurse is observing a student who is auscultating a patient's lungs. Which action by the student indicates that the nurse should intervene? a. The student compares breath sounds from side to side. b. The student starts at the base of the posterior lung and moves to the apices. c. The student places the stethoscope over the scapulae and then auscultates. d. The student listens only over the posterior part of the chest.

Correct Answer: C Rationale: The stethoscope should be placed over lung tissue, not over bony structures. Breath sounds should be compared from side to side. The techniques of starting at the lung base and then moving toward the apices and listening only over the posterior chest are acceptable. Cognitive Level: Comprehension Text Reference: p. 522 Nursing Process: Assessment NCLEX: Physiological Integrity

When admitting a patient who has a pleural effusion, which technique will the nurse use to assess for tactile fremitus? a. Percuss over the entire posterior chest. b. Use the fingertips to assess for vibration. c. Place the palms of the hands on the chest wall. d. Auscultate while the patient says "ninety-nine."

Correct Answer: C Rationale: 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." Percussion, palpation with the fingertips, and auscultation are also used during the respiratory assessment but will not assess for fremitus. Cognitive Level: Application Text Reference: p. 522 Nursing Process: Assessment NCLEX: Physiological Integrity

In reviewing the results of a patient's pulmonary function test, the nurse recognizes that a patient with COPD is likely to have an increased a. forced vital capacity. b. peak expiratory flow. c. tidal volume. d. residual volume.

Correct Answer: D Rationale: Because elastic recoil of the lungs is decreased with COPD, the residual volume is increased. Tidal volume, forced vital capacity, and peak expiratory flow rate are likely to be decreased. Cognitive Level: Comprehension Text Reference: p. 531 Nursing Process: Assessment NCLEX: Physiological Integrity

While assessing the role-relationship health pattern in a patient with respiratory problems, the nurse should specifically ask about a. any history of cigarette smoking. b. recent alterations in sexual activity. c. the course of the patient's illness. d. work exposure to respiratory irritants.

Correct Answer: D Rationale: The role-relationship pattern includes information about the occupational exposure to fumes and allergens. History of cigarette smoking and the course of the illness are assessed in the health perception-health management pattern. Alterations in sexuality are assessed in the sexuality-reproductive pattern. Cognitive Level: Application Text Reference: p. 520 Nursing Process: Assessment NCLEX: Health Promotion and Maintenance

A patient in respiratory distress is admitted to the medical unit at the hospital. During the initial assessment of the patient, the nurse should a. obtain a comprehensive health history to determine the extent of any prior respiratory problems. b. complete a full physical examination to determine the systemic effect of the respiratory distress. 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.

Correct Answer: D Rationale: 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. A focused physical assessment should be done rapidly to help determine the cause of the distress and suggest treatment. Although family members may know about the patient's history of medical problems, the patient is the best informant for these data. Cognitive Level: Application Text Reference: p. 517 Nursing Process: Assessment NCLEX: Safe and Effective Care Environment