Flashcards in LA#7 ( Respiratory) Chapters 28, 30, 31 in Med Surg Deck (137)
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1
A patient in severe respiratory distress is admitted to the medical unit at the hospital. During the admission assessment of the patient, what should the nurse do?
a. Perform a comprehensive health history with the patient to determine the extent of prior respiratory problems.
b. Complete a full physical examination to determine the effect of the respiratory distress on other body functions.
c. Delay any physical assessment of the patient, and ask family members about the patient’s history of respiratory problems.
d. Perform a physical assessment of the respiratory system, and ask specific questions related to this episode of respiratory distress.
ANS: D
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.
2
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.
ANS: B
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.
3
The physician performs a thoracentesis on a patient with a right pleural effusion. In preparing the patient for the procedure, how should the nurse position the patient?
a. Supine with the head of the bed elevated 45 degrees
b. On his left side with his right arm extended above his head
c. Sitting upright with his arms supported on an overbed table
d. On his left side in the Trendelenburg’s position with both arms extended
ANS: C
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.
4
A patient is admitted with a metabolic acidosis of unknown origin. Based on this diagnosis, the nurse would expect the patient to have which one of the following?
a. Kussmaul’s respirations
b. Slow, shallow respirations
c. A low oxygen saturation (SpO2)
d. A decrease in PVO2
ANS: A
Kussmaul’s (deep and rapid) respirations are a compensatory mechanism for metabolic acidosis.
5
While caring for a patient who has a 30-pack-year history of smoking, the nurse recognizes that the patient most likely has decreased respiratory defences due to which of the following conditions?
a. Impaired cough reflex
b. Impaired mucociliary clearance
c. Impaired reflex bronchoconstriction
d. Impaired ability to filter particles from the air
ANS: B
Smoking decreases ciliary action and the ability of the mucociliary clearance system to trap particles and move them out of the lung.
6
An 80-year-old patient breathing room air has an arterial blood gas analysis. Which of the following results does the nurse interpret as normal?
a. pH 7.32, PaO2 85 mm Hg, PaCO2 55 mm Hg, and O2 saturation 90%
b. pH 7.38, PaO2 75 mm Hg, PaCO2 40 mm Hg, and O2 saturation 92%
c. pH 7.42, PaO2 80 mm Hg, PaCO2 33 mm Hg, and O2 saturation 98%
d. pH 7.52, PaO2 90 mm Hg, PaCO2 30 mm Hg, and O2 saturation 94%
ANS: B
All of the values, pH 7.38, PaO2 75 mm Hg, PaCO2 40 mm Hg, and O2 saturation 92%, are normal.
7
A patient with amyotrophic lateral sclerosis (ALS) is admitted to the hospital with dyspnea. During palpation of the patient’s thorax, what would the nurse expect to find?
a. Diminished expansion
b. Asymmetrical expansion
c. Normal expansion of 2.5 cm
d. Unequal, diminished expansion
ANS: A
Expansion is symmetrical but diminished in conditions that produce a hyperinflated or barrel-shaped chest or in neuromuscular diseases (e.g., amyotrophic lateral sclerosis, spinal cord lesions).
8
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. How should the nurse document this finding?
a. Inspiratory wheezes in both lungs
b. Crackles in the right and left lower lobes
c. Abnormal lung sounds in the bases of both lungs
d. Pleural friction rub in the right and left lower lobes
ANS: A
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.
9
A patient with chronic obstructive pulmonary disease (COPD) has a barrel chest. What would the nurse expect the results of a chest X-ray to reveal?
a. Fluid in the alveoli
b. Air in the pleural space
c. Overinflation of the alveoli with air
d. Consolidation of lung tissue with mucus and exudates
ANS: C
A barrel chest results from lung hyperinflation and is a common finding in patients with COPD.
10
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.”
ANS: C
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 “ninety-nine.”
11
On auscultation of a patient’s lungs, the nurse hears short, low-pitched, ‘bubbling’ sounds in the right and left lower lung areas. How should the nurse document this finding?
a. Inspiratory wheezes in both lungs
b. Crackles in the right and left lower lobes
c. Abnormal lung sounds in the bases of both lungs
d. Pleural friction rub in the right and left lower lobes
ANS: B
Crackles are low-pitched, “bubbling” sounds. 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. Pleural friction rubs are grating sounds that are usually heard during both inspiration and expiration.
12
A patient with a chronic cough with blood-tinged sputum undergoes a bronchoscopy. Following the bronchoscopy, what should the nurse do?
a. Keep the patient on bed rest for 8 hours.
b. Keep the patient on nothing by mouth (NPO) status until the gag reflex returns.
c. Check vital signs every 15 minutes for 2 hours.
d. Encourage fluid intake to promote elimination of the contrast media.
ANS: B
Because a local anaesthetic is used to suppress the gag or cough reflex during bronchoscopy, the nurse should monitor for the return of these reflexes before allowing the patient to take oral fluids or food.
13
Which of the following is an age-related change in the respiratory system?
a. Increased elastic recoil of the lungs
b. Increase in chest wall compliance
c. Increase in anteroposterior diameter
d. Increase in functional alveoli
ANS: C
Many older adults have a barrel-shaped thorax as a result of an increased anteroposterior diameter.
14
While auscultating a patient’s chest as the patient takes a deep breath, the nurse hears loud, high-pitched, “blowing” sounds at both lung bases. How will the nurse document these sounds?
a. Adventitious sounds
b. Abnormal sounds
c. Vesicular sounds
d. Normal sounds
ANS: B
The description indicates that the nurse hears bronchial breath sounds that are abnormal when heard at the lung base.
15
In analyzing the results of a patient’s blood gas analysis, the nurse will be most concerned about which of the following?
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 mmol/L
ANS: A
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.
16
While assessing a patient with respiratory problems, what should the nurse specifically ask about?
a. Smoking habits
b. Alterations in sexual activity
c. The course of the patient’s illness
d. Occupational exposure to heavy lifting
ANS: A
An important aspect of a patient respiratory history, especially one with respiratory problems, is the history of smoking and smoking habits.
17
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. What does the nurse determine from this response?
a. Supplemental oxygen should be used when the patient exercises.
b. Arterial blood gas determinations should be done to verify the SpO2.
c. This finding is a normal response to activity, and the patient should continue to be monitored.
d. The oximetry probe should be moved from the finger to the earlobe for an accurate SpO2 during activity.
ANS: A
The drop in SpO2 to 85% indicates that the patient is hypoxemic and needs supplemental oxygen when exercising.
18
Which of the following is a normal partial pressure of oxygen value at sea level?
a. 60 mm Hg
b. 75 mm Hg
c. 90 mm Hg
d. 105 mm Hg
ANS: C
The normal partial pressure of oxygen at sea level is 80 to 100 mm Hg.
19
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.
ANS: 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.
20
When assessing the respiratory system of a 78-year-old patient, which of these findings indicates that the nurse should take immediate action?
a. Barrel-shaped chest
b. Weak cough effort
c. Audible crackles in the lower two thirds of the posterior chest
d. Hyperresonance across both sides of the chest
ANS: C
Crackles in the lower two thirds of the lungs indicate that the patient may have an acute problem such as congestive heart failure. The nurse should immediately accomplish further assessments, such as oxygen saturation, and notify the physician.
21
When performing an assessment of the patient’s respiratory system, the nurse uses the following illustrated technique to evaluate which of the following respiratory functions?
a. Chest expansion
b. Tactile fremitus
c. Accessory muscle use
d. Diaphragmatic excursion
ANS: A
When assessing chest expansion on the posterior chest, the nurse will place the hands at the level of the tenth rib, position the thumbs until they meet over the spine, and have the patient breathe deeply.
22
What is the normal volume of total lung capacity?
a. 1.0 L
b. 2.0 L
c. 3.5 L
d. 6.0 L
ANS: D
The normal total lung capacity volume is 6 L.
23
A patient is admitted to the emergency department complaining of sudden-onset shortness of breath and is diagnosed with a possible pulmonary embolus. To confirm the diagnosis, the nurse will anticipate preparing the patient for which of the following?
a. Chest X-ray
b. Ventilation–perfusion scan
c. Bronchoscopy
d. Positron emission tomography scan
ANS: B
A ventilation–perfusion scan is used primarily to check for the presence of a pulmonary embolus. There is no specific preparation or aftercare.
24
Which of the following is a measure of the elasticity of the lung?
a. Inspiration
b. Compliance
c. Elastic recoil
d. Oxygen–hemoglobin dissociation curve
ANS: B
Compliance (distensibility) is a measure of the elasticity of the lungs and the thorax.
25
Which of the following is an early symptom of inadequate oxygenation?
a. Dyspnea at rest
b. Hypotension
c. Tachypnea
d. Cyanosis
ANS: C
Tachypnea is an early symptom of inadequate oxygenation. Dyspnea at rest, hypotension, and cyanosis are all late signs.
26
Which is the most common infection causing acute pharyngitis?
a. Fungal
b. Viral
c. Acute follicular
d. Peritonsillar
ANS: B
Viral pharyngitis accounts for approximately 70% of all cases of acute pharyngitis.
27
When the nurse removes a nasogastric tube that has been in place for 7 days postoperatively, the patient develops a nosebleed. To control the bleeding, what should the nurse do?
a. Pinch the soft lower portion of the nose for 10 to 15 minutes.
b. Place the patient in a sitting position with the head hyperextended.
c. Apply ice compresses to the patient’s forehead and back of the neck.
d. Pack the nares with ribbon gauze to apply pressure to the source of the bleeding.
ANS: A
The first nursing action for epistaxis is to apply direct pressure by pinching the nostrils.
28
In teaching the patient with allergic rhinitis about management of the condition, what should the nurse explain?
a. Identification and avoidance of triggers of the symptoms are important to avoid reactions.
b. Allergic reactions can be prevented if oral antihistamines are taken before exposure to allergens.
c. Corticosteroid nasal sprays are the only topical drugs recommended for treatment of hay fever.
d. Prescription antihistamine drugs should be requested because over-the-counter preparations are ineffective for allergic rhinitis.
ANS: A
The most important intervention is to assist the patient to identify and avoid potential allergens.
29
A woman calls the clinic and tells the nurse that her mother, an older adult, has had a cold for the past week. The woman is worried that pneumonia will develop. After the nurse discusses care of upper respiratory infections and prevention of secondary infections, which of the following responses by the woman alerts the nurse that additional teaching is needed?
a. “I should encourage my mother to drink a lot of juices and other fluids.”
b. “I should watch for changes in nasal secretions or the sputum she coughs up.”
c. “I can give my mother aspirin or acetaminophen to make her more comfortable.”
d. “I can encourage my mother to continue to use nasal decongestant spray until the congestion is gone.”
ANS: D
The nurse should clarify that nasal decongestant sprays should be used for no more than 5 days to prevent rebound vasodilation and congestion.
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