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C25 - ch 25 test bank
Med Surg (NUR201)
Fortis College
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Chapter 25: Assessment of Respiratory System
Lewis: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
- 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.
DIF: Cognitive Level: Apply (application) REF: 459 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
- The nurse prepares a patient with a left-sided pleural effusion for a thoracentesis. How should the nurse position the patient? a. High-Fowler’s position with the left arm extended b. Supine with the head of the bed elevated 30 degrees 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.
DIF: Cognitive Level: Apply (application) REF: 471 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
- A diabetic patient’s arterial blood gas (ABG) results are pH 7; PaCO 2 34 mm Hg; PaO 2 85 mm Hg; HCO 3 – 18 mEq/L. The nurse would expect which finding? a. Intercostal retractions c. Low oxygen saturation (SpO 2 ) b. Kussmaul respirations d. Decreased venous O 2 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 O 2 pressure would not be caused by acidosis.
DIF: Cognitive Level: Apply (application) REF: 467 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
- On auscultation of a patient’s 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.
DIF: Cognitive Level: Apply (application) REF: 468 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
- 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.
DIF: Cognitive Level: Apply (application) REF: 464 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
- A patient with a chronic cough is scheduled to have a bronchoscopy with biopsy. Which intervention will the nurse implement directly after the procedure? a. Encourage the patient to drink clear liquids. b. Place the patient on bed rest for at least 4 hours. c. Keep the patient NPO until the gag reflex returns.
ANS: C For spirometry, the patient should inhale deeply and exhale as long, hard, and fast as possible. The other actions are not needed. The administration of inhaled bronchodilators should be avoided 6 hours before the procedure.
DIF: Cognitive Level: Apply (application) REF: 472 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
- The nurse observes 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 at each level. b. The student listens during the inspiratory phase, then moves the stethoscope. c. The student starts at the apices of the lungs, moving down toward the lung bases. d. The student instructs the patient to breathe slowly and deeply through the mouth.
ANS: B 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.
DIF: Cognitive Level: Apply (application) REF: 466 TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment
- A patient who has a history of chronic obstructive pulmonary disease (COPD) was hospitalized for increasing shortness of breath and chronic hypoxemia (SaO 2 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. Have the patient repeat the instructions immediately after teaching. b. Accomplish the patient teaching just before the scheduled discharge. c. Arrange for the patient’s caregiver to be present during the teaching. d. Start giving the patient discharge teaching during the admission process. ANS: C Hypoxemia interferes with the patient’s ability to learn and retain information, so having the patient’s 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.
DIF: Cognitive Level: Analyze (analysis) REF: 462 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
- A patient admitted to the emergency department complaining of sudden onset shortness of breath is diagnosed with a possible pulmonary embolus. How should the nurse prepare the patient for diagnostic testing to confirm the diagnosis? a. Ensure that the patient has been NPO.
b. Start an IV so contrast media may be given. c. Inform radiology that radioactive glucose preparation is needed. d. Instruct the patient to expect to inspire deeply and exhale forcefully.
ANS: B Spiral computed tomography scans are the most commonly used test to diagnose pulmonary emboli and contrast media may be given IV. 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 scans are most useful in determining the presence of malignancy and a radioactive glucose preparation is used. For spirometry, the patient is asked to inhale deeply and exhale as long, hard, and fast as possible.
DIF: Cognitive Level: Apply (application) REF: 470 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
- 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 past year.” b. “I became short of breath an hour before coming to the hospital.” c. “I’ve been taking Tylenol 650 mg every 6 hours for chest wall pain.” d. “I’ve 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.
DIF: Cognitive Level: Apply (application) REF: 460 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
- 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 c. Respiratory rate of 30 b. Apical pulse of 104 d. O 2 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.
DIF: Cognitive Level: Analyze (analysis) REF: 470 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
- The nurse analyzes the results of a patient’s arterial blood gases (ABGs). Which finding would require immediate action? a. The bicarbonate level (HCO 3 – ) is 31 mEq/L. b. The arterial oxygen saturation (SaO 2 ) is 92%. c. The partial pressure of CO 2 in arterial blood (PaCO 2 ) is 31 mm Hg.
c. A patient with possible lung cancer who has just returned after bronchoscopy d. A patient with hemoptysis and a 16-mm induration after tuberculin skin testing
ANS: C Because the cough and gag are decreased after bronchoscopy, this patient should be assessed for airway patency. The other patients do not have clinical manifestations or procedures that require immediate assessment by the nurse.
DIF: Cognitive Level: Analyze (analysis) REF: 463 OBJ: Special Questions: Prioritization | Special Questions: Multiple Patients TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment
- The laboratory has just called with the arterial blood gas (ABG) results on four patients. Which result is most important for the nurse to report immediately to the health care provider? a. pH 7, PaO 2 82 mm Hg, PaCO 2 40 mm Hg, and O 2 sat 97% b. pH 7, PaO 2 85 mm Hg, PaCO 2 50 mm Hg, and O 2 sat 95% c. pH 7, PaO 2 90 mm Hg, PaCO 2 32 mm Hg, and O 2 sat 98% d. pH 7, PaO 2 91 mm Hg, PaCO 2 50 mm Hg, and O 2 sat 96%
ANS: D These ABGs indicate uncompensated respiratory acidosis and should be reported to the health care provider. The other values are normal, close to normal, or compensated.
DIF: Cognitive Level: Analyze (analysis) REF: 456 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
- The nurse assesses a patient with chronic obstructive pulmonary disease (COPD) who has been admitted with increasing dyspnea over the past 3 days. Which finding is important for the nurse to report to the health care provider? a. Respirations are 36 breaths/min. b. Anterior-posterior chest ratio is 1:1. c. Lung expansion is decreased bilaterally. d. Hyperresonance to percussion is present.
ANS: A The increase in respiratory rate indicates respiratory distress and a need for rapid interventions such as administration of O 2 or medications. The other findings are common chronic changes occurring in patients with COPD.
DIF: Cognitive Level: Apply (application) REF: 460 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
- Using the illustrated technique, the nurse is assessing for which finding in a patient with chronic obstructive pulmonary disease (COPD)?
a. Hyperresonance c. Reduced excursion b. Tripod positioning d. Accessory muscle use
ANS: C The technique for palpation for chest excursion is shown in the illustrated technique. Reduced chest movement would be noted on palpation of a patient’s chest with COPD. Hyperresonance would be assessed through percussion. Accessory muscle use and tripod positioning would be assessed by inspection.
DIF: Cognitive Level: Understand (comprehension) REF: 467 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
- Which action is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)? a. Listen to a patient’s lung sounds for wheezes or crackles. b. Label specimens obtained during percutaneous lung biopsy. c. Instruct a patient about how to use home spirometry testing. d. Measure induration at the site of a patient’s intradermal skin test.
ANS: B Labeling of specimens is within the scope of practice of UAP. The other actions require nursing judgment and should be done by licensed nursing personnel.
DIF: Cognitive Level: Apply (application) REF: 471 OBJ: Special Questions: Delegation TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment
MULTIPLE RESPONSE
- A patient is scheduled for a computed tomography (CT) scan of the chest with contrast media. Which assessment findings should the nurse report to the health care provider before the patient goes for the CT (select all that apply)? a. Allergy to shellfish b. Patient reports claustrophobia c. Elevated serum creatinine level d. Recent bronchodilator inhaler use e. Inability to remove a wedding band
ANS: A, C
C25 - ch 25 test bank
Course: Med Surg (NUR201)
University: Fortis College
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