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A nurse educator is reviewing the implications of the oxyhemoglobin dissociation curve with regard to the case of a current patient. The patient currently has normal hemoglobin levels, but significantly decreased SaO2 and PaO2 levels. What is an implication of this physiological state?
- A. The patients tissue demands may be met, but she will be unable to respond to physiological stressors.
- B. The patients short-term oxygen needs will be met, but she will be unable to expel sufficient CO2.
- C. The patient will experience tissue hypoxia with no sensation of shortness of breath or labored breathing.
- D. The patient will experience respiratory alkalosis with no ability to compensate.
Correct Answer: A
Rationale: With a normal hemoglobin level of 15 mg/dL and a PaO2 level of 40 mm Hg (SaO2 75%), there is adequate oxygen available for the tissues, but no reserve for physiological stresses that increase tissue oxygen demand. If a serious incident occurs (e.g., bronchospasm, aspiration, hypotension, or cardiac dysrhythmias) that reduces the intake of oxygen from the lungs, tissue hypoxia results.
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While assessing a patient who has pneumonia, the nurse has the patient repeat the letter E while the nurse auscultates. The nurse notes that the patients voice sounds are distorted and that the letter A is audible instead of the letter E. How should this finding be documented?
- A. Bronchophony
- B. Egophony
- C. Whispered pectoriloquy
- D. Sonorous wheezes
Correct Answer: B
Rationale: This finding would be documented as egophony, which can be best assessed by instructing the patient to repeat the letter E. The distortion produced by consolidation transforms the sound into a clearly heard A rather than E. Bronchophony describes vocal resonance that is more intense and clearer than normal. Whispered pectoriloquy is a very subtle finding that is heard only in the presence of rather dense consolidation of the lungs. Sound is so enhanced by the consolidated tissue that even whispered words are heard. Sonorous wheezes are not defined as a voice sound, but rather as a breath sound.
A patient is undergoing testing to see if he has a pleural effusion. Which of the nurses respiratory assessment findings would be most consistent with this diagnosis?
- A. Increased tactile fremitus, egophony, and a dull sound upon percussion of the chest wall
- B. Decreased tactile fremitus, wheezing, and a hyperresonant sound upon percussion of the chest wall
- C. Lung fields dull to percussion, absent breath sounds, and a pleural friction rub
- D. Normal tactile fremitus, decreased breath sounds, and a resonant sound upon percussion of the chest wall
Correct Answer: C
Rationale: Assessment findings consistent with a pleural effusion include affected lung fields being dull to percussion and absence of breath sounds. A pleural friction rub may also be present. The other listed signs are not typically associated with a pleural effusion.
The nurse doing rounds at the beginning of a shift notices a sputum specimen in a container sitting on the bedside table in a patients room. The patient says the specimen is about 4 hours old. What action should the nurse take?
- A. Immediately take the sputum specimen to the laboratory.
- B. Discard the specimen and assist the patient in obtaining another specimen.
- C. Refrigerate the sputum specimen and submit it once it is chilled.
- D. Add a small amount of normal saline to moisten the specimen.
Correct Answer: B
Rationale: Sputum samples should be submitted to the laboratory as soon as possible. Allowing the specimen to stand for several hours in a warm room results in the overgrowth of contaminated organisms and may make it difficult to identify the pathogenic organisms. Refrigeration of the sputum specimen and the addition of normal saline are not appropriate actions.
A patient with a decreased level of consciousness is in a recumbent position. How should the nurse best assess the lung fields for a patient in this position?
- A. Inform that physician that the patient is in a recumbent position and anticipate an order for a portable chest x-ray.
- B. Turn the patient to enable assessment of all the patients lung fields.
- C. Avoid turning the patient, and assess the accessible breath sounds from the anterior chest wall.
- D. Obtain a pulse oximetry reading, and, if the reading is low, reposition the patient and auscultate breath sounds.
Correct Answer: B
Rationale: Assessment of the anterior and posterior lung fields is part of the nurses routine evaluation. If the patient is recumbent, it is essential to turn the patient to assess all lung fields so that dependent areas can be assessed for breath sounds, including the presence of normal breath sounds and adventitious sounds. Failure to examine the dependent areas of the lungs can result in missing significant findings. This makes the other given options unacceptable.
A patient has been diagnosed with heart failure that has not yet responded to treatment. What breath sound should the nurse expect to assess on auscultation?
- A. Expiratory wheezes
- B. Inspiratory wheezes
- C. Rhonchi
- D. Crackles
Correct Answer: D
Rationale: Crackles reflect underlying inflammation or congestion and are often present in such conditions as pneumonia, bronchitis, and congestive heart failure. Rhonchi and wheezes are associated with airway obstruction, which is not a part of the pathophysiology of heart failure.