chapter 28 Flashcards
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
When a client 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 client’s history of medical problems, the client is the best informant for
these data.
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
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 client and
make it more difficult for the health care provider performing the thoracentesis.
The nurse is caring for a client with a metabolic acidosis of unknown origin. Which of the
following findings should the nurse expect based on this diagnosis?
a. Intercostal retractions
b. Kussmaul’s respirations
c. Low oxygen saturation (SpO2)
d. Decrease in venous O2 pressure
B
Kussmaul’s (deep and rapid) respirations are a compensatory mechanism for metabolic
acidosis. Intercostal retractions, a low oxygen saturation rate, and a decrease in PvO2
would not be caused by acidosis.
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
Wheezes are high-pitched sounds. In this case they are heard during the expiratory phase
of the respiratory cycle. Abnormal breath sounds are either 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.
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
To assess for tactile fremitus, the nurse should use the palms of the hands to assess for
vibration when the client repeats a word or phrase such as “99.” Different techniques are
used to assess for dullness to percussion, decreased breath sounds, and diminished
expansion.
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
Because a local anaesthetic is used to suppress the gag or cough reflexes during
bronchoscopy, the nurse should monitor for the return of these reflexes before allowing the
client to take oral fluids or food. Blood-tinged mucus is not uncommon after bronchoscopy.
The client 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.
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 description indicates that the nurse hears bronchial breath sounds that are abnormal
when heard in the peripheral lung fields. Adventitious sounds are extra breath sounds such
as crackles, wheezes, rhonchi, and friction rubs. Vesicular sounds are low-pitched, soft
sounds heard over all lung areas except the major bronchi.
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 drop in SpO2 to 85% indicates that the client is hypoxemic and needs supplemental
oxygen when exercising. The other actions also are appropriate, but the first action should
be to correct the hypoxemia.
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
For PFT, the client should inhale deeply and exhale as long, hard, and fast as possible. The
other actions are not needed with PFT.
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 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.
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
The normal tidal volume is 500 mL
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
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.
Which of the following lung structures has the most generations?
a. Segmental bronchi
b. Subsegmental bronchi
c. Bronchioles
d. Alveoli
D
The lung structure that has the most generations is the alveoli with 28. Segmental bronchi,
subsegmental bronchi, and bronchioles have less than 28 generations.
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
All the values are abnormal, but the low PaO2 indicates that the client 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 client’s oxygenation.
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
Crackles in the lower half of the lungs indicate that the client 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,
hyper-resonance to percussion, and a weak cough effort are associated with aging. Further
evaluation may be needed, but immediate action is not indicated.
