Chapter 26: Nursing Assessment: Respiratory System 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.
Ask the patient to lie down to complete a full physical assessment.
b.
Briefly ask specific questions about this episode of respiratory distress.
c.
Complete the admission database to check for allergies before treatment.
d.
Delay the physical assessment to first complete pulmonary function tests.
ANS: B
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. Brief questioning and a focused physical assessment should be done rapidly to help determine the cause of the distress and suggest treatment. Checking for allergies is important, but it is not appropriate to complete the entire admission database at this time. The initial respiratory assessment must be completed before any diagnostic tests or interventions can be ordered.
- The nurse prepares a patient with a left-sided pleural effusion for a thoracentesis. How should the nurse position the patient?
a.
Supine with the head of the bed elevated 30 degrees
b.
In a high-Fowlers position with the left arm extended
c.
On the right side with the left arm extended above the head
d.
Sitting upright with the arms supported on an over bed table
ANS: 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 patient and make it more difficult for the health care provider performing the thoracentesis.
- A diabetic patients arterial blood gas (ABG) results are pH 7.28; PaCO2 34 mm Hg; PaO2 85 mm Hg; HCO3 18 mEq/L. The nurse would expect which finding?
a.
Intercostal retractions
b.
Kussmaul respirations
c.
Low oxygen saturation (SpO2)
d.
Decreased venous O2 pressure
ANS: B
Kussmaul (deep and rapid) respirations are a compensatory mechanism for metabolic acidosis. The low pH and low bicarbonate result indicate metabolic acidosis. Intercostal retractions, a low oxygen saturation rate, and a decrease in venous O2 pressure would not be caused by acidosis.
- On auscultation of a patients lungs, the nurse hears low-pitched, bubbling sounds during inhalation in the lower third of both lungs. How should the nurse document this finding?
a.
Inspiratory crackles at the bases
b.
Expiratory wheezes in both lungs
c.
Abnormal lung sounds in the apices of both lungs
d.
Pleural friction rub in the right and left lower lobes
ANS: A
Crackles are low-pitched, bubbling sounds usually heard on inspiration. Wheezes are high-pitched sounds. They can be heard during the expiratory or inspiratory phase of the respiratory cycle. The lower third of both lungs are the bases, not apices. Pleural friction rubs are grating sounds that are usually heard during both inspiration and expiration.
- The nurse palpates the posterior chest while the patient says 99 and notes absent fremitus. Which action should the nurse take next?
a.
Palpate the anterior chest and observe for barrel chest.
b.
Encourage the patient to turn, cough, and deep breathe.
c.
Review the chest x-ray report for evidence of pneumonia.
d.
Auscultate anterior and posterior breath sounds bilaterally.
ANS: D
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. After noting absent fremitus, the nurse should then auscultate the lungs to assess for the presence or absence of breath sounds. Absent fremitus may be noted with pneumothorax or atelectasis. The vibration is increased in conditions such as pneumonia, lung tumors, thick bronchial secretions, and pleural effusion. Turning, coughing, and deep breathing is an appropriate intervention for atelectasis, but the nurse needs to first assess breath sounds. Fremitus is decreased if the hand is farther from the lung or the lung is hyperinflated (barrel chest).The anterior of the chest is more difficult to palpate for fremitus because of the presence of large muscles and breast tissue.
- A patient with a chronic cough has a bronchoscopy. After the procedure, which intervention by the nurse is most appropriate?
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 after bronchoscopy.
d.
Notify the health care provider about blood-tinged mucus.
ANS: B
Risk for aspiration and maintaining an open airway is the priority. 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. Blood-tinged mucus is not uncommon after bronchoscopy. The patient does not need to be on bed rest, and the head of the bed does not need to be in the high-Fowlers position.
- The nurse completes a shift assessment on a patient admitted in the early phase of heart failure. When auscultating the patients lungs, which finding would the nurse most likely hear?
a.
Continuous rumbling, snoring, or rattling sounds mainly on expiration
b.
Continuous high-pitched musical sounds on inspiration and expiration
c.
Discontinuous, high-pitched sounds of short duration heard on inspiration
d.
A series of long-duration, discontinuous, low-pitched sounds during inspiration
ANS: C
Fine crackles are likely to be heard in the early phase of heart failure. Fine crackles are discontinuous, high-pitched sounds of short duration heard on inspiration. Rhonchi are continuous rumbling, snoring, or rattling sounds mainly on expiration. Course crackles are a series of long-duration, discontinuous, low-pitched sounds during inspiration. Wheezes are continuous high-pitched musical sounds on inspiration and expiration.
- While caring for a patient with respiratory disease, the nurse observes that the patients SpO2 drops from 93% to 88% while the patient is ambulating in the hallway. What is the priority action of the nurse?
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.
ANS: C
The drop in SpO2 to 85% indicates that the patient is hypoxemic and needs supplemental oxygen when exercising. The other actions are also important, but the first action should be to correct the hypoxemia.
- The nurse teaches a patient about pulmonary function testing (PFT). Which statement, if made by the patient, indicates teaching was effective?
a.
I will use my inhaler right before the test.
b.
I wont eat or drink anything 8 hours before the test.
c.
I should inhale deeply and blow out as hard as I can during the test.
d.
My blood pressure and pulse will be checked every 15 minutes after the test.
ANS: C
For PFT, the patient should inhale deeply and exhale as long, hard, and fast as possible. The other actions are not needed with PFT. The administration of inhaled bronchodilators should be avoided 6 hours before the procedure.
- The nurse observes a student who is listening to a patients lungs who is having no problems with breathing. Which action by the student indicates a need to review respiratory assessment skills?
a.
The student starts at the apices of the lungs and moves to the bases.
b.
The student compares breath sounds from side to side avoiding bony areas.
c.
The student places the stethoscope over the posterior chest and listens during inspiration.
d.
The student instructs the patient to breathe slowly and a little more deeply than normal through the mouth.
ANS: C
Listening only during inspiration indicates the student needs a review of respiratory assessment skills. At each placement of the stethoscope, listen to at least one cycle of inspiration and expiration. During chest auscultation, instruct the patient to breathe slowly and a little deeper than normal through the mouth. Auscultation should proceed from the lung apices to the bases, comparing opposite areas of the chest, unless the patient is in respiratory distress or will tire easily. If so, start at the bases (see Fig. 26-7). Place the stethoscope over lung tissue, not over bony prominences.
- A patient who has a history of chronic obstructive pulmonary disease (COPD) was hospitalized for increasing shortness of breath and chronic hypoxemia (SaO2 levels of 89% to 90%). In planning for discharge, which action by the nurse will be most effective in improving compliance with discharge teaching?
a.
Start giving the patient discharge teaching on the day of admission.
b.
Have the patient repeat the instructions immediately after teaching.
c.
Accomplish the patient teaching just before the scheduled discharge.
d.
Arrange for the patients caregiver to be present during the teaching.
ANS: D
Hypoxemia interferes with the patients ability to learn and retain information, so having the patients caregiver 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.
- A patient is admitted to the emergency department complaining of sudden onset shortness of breath and is diagnosed with a possible pulmonary embolus. How should the nurse prepare the patient for diagnostic testing to confirm the diagnosis?
a.
Start an IV so contrast media may be given.
b.
Ensure that the patient has been NPO for at least 6 hours.
c.
Inform radiology that radioactive glucose preparation is needed.
d.
Instruct the patient to undress to the waist and remove any metal objects.
ANS: A
Spiral computed tomography (CT) scans are the most commonly used test to diagnose pulmonary emboli, and contrast media may be given IV. A chest x-ray may be ordered but will not be diagnostic for a pulmonary embolus. Preparation for a chest x-ray includes undressing and removing any metal. Bronchoscopy is used to detect changes in the bronchial tree, not to assess for vascular changes, and the patient should be NPO 6 to 12 hours before the procedure. Positron emission tomography (PET) scans are most useful in determining the presence of malignancy, and a radioactive glucose preparation is used.
- The nurse admits a patient who has a diagnosis of an acute asthma attack. Which statement indicates that the patient may need teaching regarding medication use?
a.
I have not had any acute asthma attacks during the last year.
b.
I became short of breath an hour before coming to the hospital.
c.
Ive been taking Tylenol 650 mg every 6 hours for chest-wall pain.
d.
Ive been using my albuterol inhaler more frequently over the last 4 days.
ANS: D
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.
- A patient with acute dyspnea is scheduled for a spiral computed tomography (CT) scan. Which information obtained by the nurse is a priority to communicate to the health care provider before the CT?
a.
Allergy to shellfish
b.
Apical pulse of 104
c.
Respiratory rate of 30
d.
Oxygen saturation of 90%
ANS: A
Because iodine-based contrast media is used during a spiral CT, the patient may need to have the CT scan without contrast or be premedicated before injection of the contrast media. The increased pulse, low oxygen saturation, and tachypnea all indicate a need for further assessment or intervention but do not indicate a need to modify the CT procedure.
- The nurse analyzes the results of a patients arterial blood gases (ABGs). Which finding would require immediate action?
a.
The bicarbonate level (HCO3) is 31 mEq/L.
b.
The arterial oxygen saturation (SaO2) is 92%.
c.
The partial pressure of CO2 in arterial blood (PaCO2) is 31 mm Hg.
d.
The partial pressure of oxygen in arterial blood (PaO2) is 59 mm Hg.
ANS: D
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 patients oxygenation.
