Lewis Chapter 26 Flashcards
A patient with acute shortness of breath is admitted to the hospital. Which action should the nurse take during the initial assessment of the patient?
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. Perform a respiratory system assessment and ask specific questions about this episode of respiratory distress.
When preparing the patient with a right-sided pleural effusion for a thoracentesis, how will the nurse position the patient?
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. Sitting upright with the arms supported on an over bed table
A patient is admitted with a metabolic acidosis of unknown origin. Based on this diagnosis, the nurse would expect the patient to have
a. intercostal retractions.
b. Kussmaul respirations.
c. a low oxygen saturation (SpO2).
d. a decrease in venous O2 pressure.
b. Kussmaul respirations.
On auscultation of a patient’s lungs, the nurse hears short, high-pitched sounds during exhalation in the lower 1/3 of both lungs. The nurse records this finding as
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. expiratory wheezes in both lungs.
The nurse palpates the posterior chest while the patient says “99” and notes that no vibration is felt. How should this be charted?
a. Diminished expansion
b. Dullness to percussion
c. Absent tactile fremitus
d. Decreased breath sounds
c. Absent tactile fremitus
A patient with a chronic cough has a bronchoscopy. Which action will be included in the nursing care plan after the procedure?
a. Elevate the head of the bed to 80 to 90 degrees.
b. Keep the patient 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. Keep the patient NPO until the gag reflex returns.
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. normal sounds.
b. vesicular sounds.
c. abnormal sounds.
d. adventitious sounds.
c. abnormal sounds.
While caring for a patient with respiratory disease, the nurse observes that the patient’s SpO2 drops from 92% to 88% while the patient is ambulating in the hallway. Which action 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 patient to pace activity.
c. Administer the PRN supplemental O2
Which action will the nurse plan to take for a patient 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. Teach deep inhalation and forceful exhalation.
The nurse is observing a student who is listening to a patient’s lungs. Which action 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 student places the stethoscope over the scapulae and then auscultates.
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 a
a. positron emission tomography (PET) scan.
b. chest x-ray.
c. bronchoscopy.
d. spiral computed tomography (CT) scan.
d. spiral computed tomography (CT) scan
A patient with acute dyspnea is scheduled for a spiral computed tomography (CT) scan. Which information obtained by the nurse is most important to communicate to the health care provider before the CT?
a. The apical pulse is 102.
b. The respiratory rate is 32.
c. The oxygen saturation is 93%.
d. The patient is allergic to shellfish.
d. The patient is allergic to shellfish.
When the nurse is analyzing the results of a patient’s arterial blood gases (ABGs), which finding indicates the need for 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 mEq/L.
b. The partial pressure of oxygen in arterial blood (PaO2) is 59 mm Hg.
When assessing the respiratory system of a 78-year-old patient, which finding indicates that the nurse should take immediate action?
a. The chest appears barrel shaped.
b. The patient 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 are heard from the lung bases to the midline.
A hypothermic patient is admitted to the emergency department, and pulse oximetry (SpO2) indicates that the O2 saturation is 96%. Which action should the nurse take next?
a. Initiate rewarming of the patient.
b. Complete a head-to-toe assessment.
c. Obtain arterial blood gases (ABGs).
d. Place the patient on high-flow oxygen.
d. Place the patient on high-flow oxygen.
