Nokea
A nurse is obtaining a health history from a client who reports hemoptysis for the past 2 months. The client reports occasional dyspnea. Which imaging study, ordered by the physician, will view the thoracic cavity while in motion?
- A. Fluoroscopy
- B. Chest x-ray
- C. Magnetic resonance imaging (MRI)
- D. Computed tomography (CT) scan
Correct Answer: A
Rationale: Fluoroscopy enables the physician to view the thoracic cavity with all of its contents in motion. A fluoroscopy more precisely diagnoses the location of a tumor or lesion. An x-ray shows the size, shape, and position of the lungs. An MRI and CT produce axial views of the lungs.
You may also like to solve these questions
What happens to the diaphragm during inspiration?
- A. It relaxes and raises.
- B. It contracts and flattens.
- C. It relaxes and flattens.
- D. It contracts and raises.
Correct Answer: B
Rationale: During inspiration, the diaphragm contracts and flattens, which expands the thoracic cage and increases the thoracic cavity.
A client arrived in the emergency department with a sharp object penetrating the diaphragm. When planning nursing care, which client need would the nurse identify as a priority?
- A. Acute pain
- B. Infection risk
- C. Impaired gas exchange
- D. Ineffective airway clearance
Correct Answer: C
Rationale: The diaphragm separates the thoracic and abdominal cavities. On inspiration, the diaphragm contracts and moves downward, creating a partial vacuum. Without this vacuum, air is not as efficiently drawn into the thoracic cavity. Hypoxia or hypoxemia may occur from the poor availability of oxygen. Although the nursing diagnosis of acute pain is probable, gas exchange is a higher priority. Ineffective airway clearance is not the greatest concern because the problem is with ventilation. Infection risk is present but is not the highest-priority client need.
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 an adolescent client injured in a snowboarding accident. The client has a head injury, a fractured right rib, and various abrasions and contusions. The client has a blood pressure of 142/88 mm Hg, pulse of 102 beats/minute, and respirations of 26 breaths/minute. Which laboratory test best provides data on a potential impairment in ventilation?
- A. Blood gases
- B. Complete blood count
- C. Blood chemistry
- D. Serum alkaline phosphate
Correct Answer: A
Rationale: Blood gases report the partial pressure of oxygen, which is dissolved in the blood. Normal readings are 80 to 100 mm Hg. By documenting oxygen levels in the blood, the nurse recognizes the current ventilation. The complete blood count provides information regarding number of blood cells, which can relate to the disease processes such as anemia and infection. The blood chemistry provides information on liver/renal function and electrolytes within the system. Serum alkaline phosphate is a laboratory test used to help detect liver disease and bone disorders.
The nurse is caring for a client with a decrease in airway diameter causing airway resistance. The client experiences coughing and mucus production. On lung assessment, which adventitious breath sounds are anticipated?
- A. Crackles
- B. Sonorous wheezes
- C. Rubs
- D. Sibilant wheezes
Correct Answer: D
Rationale: A decrease in airway diameter, such as in asthma, produces breath sounds of wheezes. Wheezes may be sibilant (hissing or whistling) or sonorous (full and deep). Sibilant wheezes (formerly called wheezes) are continuous musical sounds that can be heard during inspiration and expiration. They result from air passing through narrowed or partially obstructed air passages and are heard in clients with increased secretions. Sonorous wheezes (formerly called rhonchi) are lower pitched and are heard in the trachea and bronchi. Sonorous wheezes are coarse, rattling sounds similar to snoring usually caused by secretion in the bronchial tree. Crackles, also called rales, are crackling or rattling sounds signifying fluid or exudate in the lung fields. Rubs are secretions that can be heard in the large airway.