Nokea
A client arrives at the physician's office stating dyspnea; a productive cough for thick, green sputum; respirations of 28 breaths/minute, and a temperature of 102.8?°F The nurse auscultates the lung fields, which reveal poor air exchange in the right middle lobe. The nurse suspects a right middle lobe pneumonia. To be consistent with this anticipated diagnosis, which sound, heard over the chest wall when percussing, is anticipated?
- A. Tympanic
- B. Resonant
- C. Hyperresonant
- D. Dull
Correct Answer: D
Rationale: A dull percussed sound, heard over the chest wall, is indicative of little or no air movement in that area of the lung. Lung consolidation such as in pneumonia or fluid accumulation produces the dull sound. A tympanic sound is a high-pitched sound commonly heard over the stomach or bowel. A resonant sound is noted over normal lung tissue. A hyperresonant sound is an abnormal lower pitched sound that occurs when free air exists in disease processes such as pneumothorax.
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A nurse is caring for a client who has frequent upper respiratory infections. Which structure is most helpful in protecting against infection?
- A. Cilia
- B. Sinus cavity
- C. Tonsils
- D. Turbinates
Correct Answer: C
Rationale: Tonsils and adenoids do not contribute to respiration but protect against infection. Palatine tonsils are composed of lymphoid tissue. Cilia are fine hairs that move particles and liquid, preventing irritation and contamination of the airway. Sinuses are nasal cavity structures. Turbinates warm and add moisture to the inspired air.
The nurse is caring for a client whose respiratory status has declined since shift report. The client has tachypnea, is restless, and displays cyanosis. Which diagnostic test should the nurse perform first?
- A. Arterial blood gases
- B. Pulmonary function test
- C. Pulse oximetry
- D. Chest x-ray
Correct Answer: C
Rationale: Pulse oximetry is a noninvasive method to determine arterial oxygen saturation. Normal values are 95% and above. Using this diagnostic test first provides rapid information of the client's respiratory system. All other options vary in amount of time and patient participation in determining further information regarding the respiratory system.
What is the difference between respiration and ventilation?
- A. Ventilation is the process of gas exchange.
- B. Ventilation is the movement of air in and out of the respiratory tract.
- C. Ventilation is the process of getting oxygen to the cells.
- D. Ventilation is the exchange of gases in the lung.
Correct Answer: B
Rationale: Ventilation is the actual movement of air in and out of the respiratory tract. Respiration is the exchange of oxygen and CO2 between atmospheric air and the blood and between the blood and the cells.
The client is returning from the operating room following a bronchoscopy. Which action, performed by the nursing assistant, would the nurse stop if began prior to nursing assessment?
- A. The nursing assistant is assisting the client to a semi-Fowler's position.
- B. The nursing assistant is assisting the client to the side of the bed to use a urinal.
- C. The nursing assistant is pouring a glass of water to wet the client's mouth.
- D. The nursing assistant is asking a question requiring a verbal response.
Correct Answer: C
Rationale: When completing a procedure which sends a scope down the throat, the gag reflex is anesthetized to reduce discomfort. Upon returning to the nursing unit, the gag reflex must be assessed before providing any food or fluids to the client. The client may need assistance following the procedure for activity and ambulation but this is not restricted in the post-procedure period.
The nurse is caring for a client with an exacerbation of COPD and scheduled for pulmonary function studies using a spirometer. Which client statement would the nurse clarify?
- A. My study is scheduled for 10 AM, several hours after I eat.'
- B. I brought comfortable clothes and shoes for the test.'
- C. I am ordered a bronchodilator to note lung improvement following use.'
- D. I will breathe in through my mouth and out through my nose.'
Correct Answer: D
Rationale: The nurse would clarify the client's statement of improper breathing technique. During a pulmonary function test using a spirometer, a nose clip prevents air from escaping through the client's nose when blowing into the spirometer. All other statements are correct.