HESI Case Study- Respiratory

Question 1

Client is a 70-year-old male. He has a history of emphysema and has been admitted to an inpatient medical unit with an acute respiratory infection. The nurse prepares to complete the client’s admission assessment after client’s transfer from the emergency department (ED).

To ensure that the client’s respiratory status is stable upon his arrival on the medical unit, the nurse should complete which assessment first?

Breath sounds.

Oxygen saturation.

Level of fatigue.

Chest excursion.

Answer 1

Oxygen saturation.

Measurement of the client’s oxygen saturation provides information about the effectiveness of gas exchange. A low oxygen saturation level requires immediate nursing intervention.

Question 2

The initial assessment of client continues. The nurse measures the client’s vital signs. His respiratory rate is 32 breaths per minute.

What follow-up assessment data should the nurse obtain first?

Cigarette smoking history.

Use of accessory muscles.

Cultural health beliefs.

Color of sputum.

Answer 2

Use of accessory muscles.

Use of accessory muscles indicates an increased respiratory effort by the client and indicates that the client may be experiencing respiratory distress.

Question 3

The nurse applies oxygen at 2 liters per minute (2L/min) via a nasal cannula and ensures that the client is comfortable. His oxygen saturation is stable at 95%, and his respiratory rate decreases to 24 breaths per minute. Client reports that he feels able to continue with the admission interview and assessment.

After answering a few questions, the client begins to cough. What assessment should the nurse perform?

Assess for the presence of nail bed clubbing.

Review oral fluid intake for the last 24 hours.

Observe for dryness of the oral mucosa.

Note the amount and appearance of any sputum.

Answer 3

Note the amount and appearance of any sputum.

The amount and appearance of any sputum when the client coughs provides useful data related to the cause of the client’s cough and any underlying problems.

Question 4

Client’s cough is non-productive.

After client stops coughing, the nurse continues the interview. To assess the client’s history related to dyspnea on exertion (DOE), what question should the nurse ask?

“Do you become short of breath while lying flat?”

“What activities cause you to feel short of breath?”

“How frequently do you experience difficulty breathing?”

“Are you having trouble catching your breath right now?”

Answer 4

“What activities cause you to feel short of breath?”

The type of activity and the amount of physical effort should elicit information about the client’s DOE.

Question 5

The nurse asks client about his history of cigarette smoking. He tells the nurse that he smoked two packs of cigarettes per day for more than 40 years, but then he quit smoking 10 years ago. He then looks away and remarks that he is very fatigued from answering all the interview questions.

How should the nurse respond?

Continue the interview and assessment, avoiding further questions related to cigarette smoking.

Restrict visitors so that the client can rest, and return later to complete the interview and assessment.

Advise the client to rest in the bed while the nurse performs a physical assessment of the client.

Document that the physical assessment could not be performed because of the client’s level of fatigue.

Answer 5

Advise the client to rest in the bed while the nurse performs a physical assessment of the client.

Since it is important to obtain as much assessment data as possible to ensure the client’s physiologic stability, the nurse should continue with the client’s physical assessment but allow the client to rest by curtailing the interview.

Question 6

While client rests, the nurse continues the physical assessment. The nurse observes the appearance of his thorax and notes that the ratio of his anteroposterior and transverse chest diameters is 1:1.

How should this finding be documented?

Within normal limits.

Funnel chest.

Barrel chest.

Thoracic scoliosis.

Answer 6

Barrel chest.

A barrel chest is the description for an increased anteroposterior (AP) to transverse ratio. The normal ratio is 1:2, so a 1:1 ratio represents an increased ratio.

Question 7

The nurse observes client for outward signs of hypoxemia. The nurse notes that his skin color to be normal and that his nail beds are pink.

What additional assessment will provide supporting data related to hypoxemia? (Select all that apply. One, some, or all options may be correct.)

Color of palms and soles.

Evidence of lower leg swelling.

Presence and location of chest hair.

Multiple thoracic hemangiomas.

Shape of the fingers and fingertips.

Answer 7

Color of palms and soles.
Shape of the fingers and fingertips.

Question 8

The nurse reviews landmarks on the anterior chest and locates the Angle of Louis.

Locating the Angle of Louis is important to guide the nurse in next locating what area?

Xiphoid process.

Erb’s point.

Clavicle.

Second rib.

Answer 8

Second rib.

The second ribs attach to the sternum at the Angle of Louis, or sternal angle. This landmark is located at the bottom of the manubrium of the sternum, is felt as a bony ridge, and is the point where the treachea bifurcates into the right and left stem bronchi.

Question 9

Client asks to sit on the side of the bed. After assisting him to this position, the nurse continues the assessment, facing client’s back and placing both hands on his posterolateral chest at the level of T9.

To assess chest excursion, what should the nurse do next?

Ask the client to inhale deeply.

Encourage the client to cough.

Tap lightly over the middle finger.

Instruct the client to hold his breath.

Answer 9

Ask the client to inhale deeply.

To assess chest excursion, the nurse observes the movement of the hands placed on the lower posterior thorax as the client inhales.

Question 10

The nurse observes symmetric chest excursion. What action should the nurse take?

Ask the client to cough before repeating the assessment.

Document the normal finding on the assessment record.

Question the client about a recent history of rib fractures.

Stop the assessment and measure the client’s vital signs.

Answer 10

Document the normal finding on the assessment record.

Question 11

The nurse next plans to palpate for vocal fremitus.

Recalling the client’s admission diagnosis of emphysema and an acute pulmonary infection, what finding should the nurse anticipate?

Diminished fremitus over areas of infection.

Increased fremitus over areas of consolidation.

Absent fremitus over areas of hyperinflated alveoli.

Inability to assess for fremitus due to fatigue.

Answer 11

Increased fremitus over areas of consolidation.

Increased fremitus, or vibration when the client speaks, is often felt over areas of consolidated lung tissue, such as in clients with pneumonia.

Question 12

To begin the assessment for vocal fremitus, what should the nurse do?

Place one hand over each scapula.

Locate the posterior axillary line.

Assist the client to lie back in the bed.

Ask the client to repeat a phrase aloud.

Answer 12

Ask the client to repeat a phrase aloud.

Vocal fremitus is assessed by palpating for vibrations on the thoracic wall beginning at the apex and ending at the base of the lungs while the client repeats a word or phrase aloud.

Question 13

Since client is still comfortable sitting on the side of the bed leaning over a bedside table, the nurse next prepares to percuss his thorax.

In order to percuss the client’s thorax posteriorly beginning at the apex of the right lung, how should the nurse begin?

Palpate the space directly below the clavicle.

Place one finger pad over the first rib.

Locate the client’s first intercostal space.

Find the space directly above the diaphragm.

Answer 13

Locate the client’s first intercostal space.

Percussion should be performed systematically, percussing in the intercostal spaces to avoid the ribs and scapulae.

Question 14

The nurse percusses the client’s lungs bilaterally and notes dullness in the lung bases.

What follow-up action should the nurse implement?

Compare this finding with the location of the client’s pneumonia seen on x-ray.

Review the client’s medical history to determine how long he has had emphysema.

Document this normal assessment finding in the client’s admission assessment.

Notify the healthcare provider (HCP) that the client may have developed a pneumothorax.

Answer 14

Compare this finding with the location of the client’s pneumonia seen on x-ray.

Dullness upon percussion should be anticipated over areas of abnormal density, including pneumonia. The nurse can confirm this assessment finding by reviewing the location of the client’s pneumonia found on x-ray.

Question 15

Client remains seated on the side of the bed. The nurse begins to auscultate his breath sounds posteriorly by placing the diaphragm of the stethoscope over his left lung apex.

After listening in this area, how should the nurse proceed?

Move the diaphragm across to the apex of the right lung posteriorly.

Listen again at the same location using the bell of the stethoscope.

Stand in front of the client and listen to the left lung apex anteriorly.

Inch down the left side posteriorly to listen to the left middle lobe.

Answer 15

Move the diaphragm across to the apex of the right lung posteriorly.

Moving the diaphragm of the stethoscope across the posterior thorax provides the most systematic approach to comparing the lung sounds bilaterally.

Question 16

The nurse hears vesicular breath sounds when auscultating over the upper and middle lung fields posteriorly.

What action should the nurse take?

Encourage the client to cough and then auscultate these lung fields again.

Stop the assessment immediately and administer a PRN dose of an inhaler.

Continue the assessment after documenting the location of these abnormal sounds.

Auscultate the lower lung fields to determine the presence of any adventitious sounds.

Answer 16

Auscultate the lower lung fields to determine the presence of any adventitious sounds.

Since vesicular breath sounds are normally heard in the peripheral lung fields, the nurse should continue to auscultate the remaining lung fields, listening for any abnormal, or adventitious, sounds.

Question 17

The nurse hears crackles bilaterally in the posterior lung bases. After the nurse completes auscultation of the breath sounds posteriorly, client states he is ready to swing his legs back on the bed and rest. The nurse assists the client to a Semi-Fowler’s position, ensuring that his oxygen remains in place. With client resting in bed in this position, the nurse auscultates the breath sounds anteriorly. The nurse hears high-pitched musical squeaking sounds in the upper lobes during expiration.

What action should the nurse take?

Document the presence of wheezes in the upper lobes and complete the assessment.

Immediately assist the client to lean forward to reduce his respiratory effort.

Note the location of these bronchial breath sounds before completing the assessment.

Wait to assess these heart sounds until the respiratory assessment is complete.

Answer 17

Document the presence of wheezes in the upper lobes and complete the assessment.

Wheezes may be present in clients with chronic emphysema when diffuse airway obstruction occurs.

Question 18

Although crackles could be heard bilaterally during the posterior auscultation of the lung bases, the nurse does not hear any adventitious sounds in the lung bases during anterior auscultation.

What action should the nurse take?

Reassure the client that his lung sounds are improving.

Document that the lung bases are clear upon auscultation.

Document what was heard both anteriorly and posteriorly.

Record only the location of the abnormal breath sounds.

Answer 18

Document what was heard both anteriorly and posteriorly.

Although abnormal breath sounds in the lung bases may be heard only from the posterior, it is important to document the sounds heard both anteriorly and posteriorly.

Question 19

Since client has a history of emphysema, the nurse recognizes that he may have an alteration in his nutritional intake and is not getting enough nutrients. To assess client’s nutritional status, the nurse first notes the client’s height and weight that were obtained by the nurse in the emergency department.

Which assessment provides the most useful data related to the client’s current nutritional status?

Calculate the client’s body mass index (BMI).

Ask the client about any recent changes in his appetite.

Assist the client to complete a 24-hour diet recall.

Check the client’s serum hemoglobin A1c level.

Answer 19

Calculate the client’s body mass index (BMI).
Body mass index (BMI) is a marker of the client’s optimal weight for his height and provides important data related to the client’s current nutritional status.

Question 20

The nurse weighs client, who is 132 pounds. The nurse records the weight in kilograms. How many kilograms does he weigh?

Answer 20

60kg

Rationale: 1 lb = 2.2 kgLb divided by 2.2 kg = x132 lbs divided by 2.2 kg = 60

Question 21

Using the client’s height and weight, the nurse calculates the client’s BMI to be 15, indicating that the client is underweight for his height. Since this finding supports the nurse’s initial problem of an alteration in his nutritional intake, the nurse decides to gather more assessment data related to the his nutritional status.

To assess the client for signs of protein malnutrition, what action should the nurse take?

Compress the client’s nail beds.

Observe the color of the conjunctiva.

Note the texture of the client’s hair.

Measure the client’s deep tendon reflexes.

Answer 21

ote the texture of the client’s hair.

Dull, dry, sparse hair may be an indication of nutritional deficiencies, including protein deficiency.

Question 22

Later that day, the UAP reports a change in client’s vital signs, with an increase in temperature from 101° F to 103° (38.3 oC to 39.4oC) F. The UAP reports the information to the nurse, who goes to the client’s room to assess the client. The nurse observes sputum in a tissue left at the bedside. The sputum is thick and purulent.

What assessment should the nurse perform?

Palpate for changes in vocal fremitus.

Auscultate breath sounds bilaterally.

Observe the thoracic diameter ratio.

Percuss for diaphragmatic excursion.

Answer 22

Auscultate breath sounds bilaterally.

Thick, purulent sputum is a sign of an infectious process. The nurse should auscultate the client’s lungs to determine if a change from the previous assessment has occurred, reflecting a worsening of the client’s condition.

Question 23

During the assessment, the nurse also observes that client is confused. During the admission interview and assessment, client was oriented to person, place, and time. The nurse auscultates his breath sounds and hears an increase in crackles posteriorly, now in both the lower and middle lung fields.

Which data is most important for the nurse to obtain before contacting the HCP?

Pedal pulse volume.

Orientation to situation.

White blood cell count.

Respiratory effort.

Answer 23

Respiratory effort.

Confusion may be an indicator of decreasing oxygenation, especially in the older person. Based on the client’s signs of worsening pneumonia coupled with the confusion, his respiratory rate and effort along with his oxygen saturation level should be obtained before the nurse contacts the HCP.

Question 24

The nurse documents the assessment findings and prepares to contact the client’s HCP.

When recording the change in the client’s assessment findings, how should the nurse document the breath sounds?

Adventitious breath sounds present in the middle and lower lungs bilaterally.

Client’s posterior breath sounds have worsened from the earlier assessment.

Crackles heard bilaterally in the middle and lower lung fields posteriorly.

Bilateral normal breath sounds heard only in the upper lobes posteriorly.

Answer 24

rackles heard bilaterally in the middle and lower lung fields posteriorly.

This documentation provides a clear, concise picture of the current assessment findings.

Question 25

The nurse places a telephone call to client’s HCP, an internist.

How should the nurse report the assessment data?

Provide the internist with a full report of the initial assessment data obtained upon the client’s admission only.

Describe only the most current assessment data and the changes observed after the client’s temperature increased.

Compare the current assessment of the client to the data obtained during the admission assessment of the client.

Notify the internist that the client’s condition has changed, but avoid giving specific data until the internist assesses the client.

Answer 25

Compare the current assessment of the client to the data obtained during the admission assessment of the client.

This report will provide the most complete client data, enabling the internist to make the most effective decisions about any changes needed in the client’s medical care.