Harding chapter 25 evolve
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? 2 minutes 5 minutes 10 minutes 15 minutes
5 minutes Rationale: 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.
Which patient has early clinical manifestations of hypoxemia? A 48-yr-old patient who is intoxicated and acutely disoriented to time and place. A 67-yr-old patient who has dyspnea while resting in the bed or in a reclining chair. A 72-yr-old patient who has four new premature ventricular contractions per minute. A 94-yr-old patient who has renal insufficiency, anemia, and decreased urine output.
A 72-yr-old patient who has four new premature ventricular contractions per minute. Rationale: 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.
When assessing the patient in 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
A and D cyanosis and. accessory muscle use. 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.
A patient is hospitalized with pneumonia. Which diagnostic test should be used to measure the efficiency of gas exchange in the lung and tissue oxygenation? Thoracentesis Bronchoscopy Arterial blood gases Pulmonary function tests
Arterial blood gases Rationale: 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 is performing a focused respiratory assessment of a 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
Auscultation of bilateral breath sounds Rationale: 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.
A frail older adult 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? Bases of the posterior chest area Apices of the posterior lung fields Anterior chest area above the breasts Midaxillary on the left side of the chest
Bases of the posterior chest area Rationale: 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.
When auscultating the patient's lower lungs, the nurse hears low-pitched sounds similar to blowing through a straw under water on inspiration. How should the nurse document these sounds? Stridor Vesicular Coarse crackles Bronchovesicular
Coarse crackles Rationale: 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.
The patient is calling the clinic with a cough. What assessment should be made first before the nurse advises the patient? Frequency, family history, hematemesis Cough sound, sputum production, pattern Weight loss, activity tolerance, orthopnea Smoking status, medications, residence location
Cough sound, sputum production, pattern Rationale: 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.
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? Decreased response to hypercapnia Decreased number of functional alveoli Increased calcification of costal cartilage Decreased respiratory defense mechanisms
Decreased respiratory defense mechanisms Rationale: 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.
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
Fingernails Rationale: 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.
A patient has metabolic acidosis secondary to type 1 diabetes. What physiologic response should the nurse expect to assess in the patient? Vomiting Increased urination Decreased heart rate Increased respiratory rate
Increased respiratory rate Rationale: 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.
When assessing a patient's sleep-rest pattern related to respiratory health, what should the nurse ask the patient? (Select all that apply.) a. Is it hard for you to fall asleep? b. Do you awaken abruptly during the night? c. Do you sleep more than 8 hours per night? d. Do you need to sleep with the head elevated? e. Do you often need to urinate during the night?
Is it hard for you to fall asleep? Do you awaken abruptly during the night? Do you need to sleep with the head elevated? Rationale: 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 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.
Monitor the patient for laryngeal edema. Rationale: 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.
After assisting at the bedside with a thoracentesis, the nurse should continue to assess the patient for signs and symptoms of what?Bronchospasm Pneumothorax Pulmonary edema Respiratory acidosis
Pneumothorax Rationale: 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.
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)
Positron emission tomography (PET) Rationale: 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.
The patient's arterial blood gas results show the PaO2 at 65 mmHg and SaO2 at 80%. What other 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. Restlessness, tachypnea, tachycardia, and diaphoresis With inadequate oxygenation, early manifestations include restlessness, tachypnea, tachycardia, and diaphoresis, decreased urinary output, and unexplained fatigue. 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 are later manifestations of inadequate oxygenation.
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. After surgery, 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
The patient with Parkinson's disease has a pulse oximetry reading of 72% but has no other signs of decreased oxygenation. What is the most likely explanation for the low SpO2 level? Anemia Artifact Dark skin color Thick acrylic nailsIncorrect Answer
b. artifact 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.
The nurse is interpreting a tuberculin skin test (TST) for a patient with end-stage renal disease due to diabetes. 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.
A 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 is palpating the patient's chest during a focused respiratory assessment in the emergency department. 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.
