Nokea
A patient is scheduled to have excess pleural fluid aspirated with a needle in order to relieve her dyspnea. The patient inquires about the normal function of pleural fluid. What should the nurse describe?
- A. It allows for full expansion of the lungs within the thoracic cavity.
- B. It prevents the lungs from collapsing within the thoracic cavity.
- C. It limits lung expansion within the thoracic cavity.
- D. It lubricates the movement of the thorax and lungs.
Correct Answer: D
Rationale: The visceral pleura cover the lungs; the parietal pleura line the thorax. The visceral and parietal pleura and the small amount of pleural fluid between these two membranes serve to lubricate the thorax and lungs and permit smooth motion of the lungs within the thoracic cavity with each breath. The pleura do not allow full expansion of the lungs, prevent the lungs from collapsing, or limit lung expansion within the thoracic cavity.
You may also like to solve these questions
The nurse is caring for an elderly patient in the PACU. The patient has had a bronchoscopy, and the nurse is monitoring for complications related to the administration of lidocaine. For what complication related to the administration of large doses of lidocaine in the elderly should the nurse assess?
- A. Decreased urine output and hypertension
- B. Headache and vision changes
- C. Confusion and lethargy
- D. Jaundice and elevated liver enzymes
Correct Answer: C
Rationale: Lidocaine may be sprayed on the pharynx or dropped on the epiglottis and vocal cords and into the trachea to suppress the cough reflex and minimize discomfort during a bronchoscopy. After the procedure, the nurse will assess for confusion and lethargy in the elderly, which may be due to the large doses of lidocaine administered during the procedure. The other listed signs and symptoms are not specific to this problem.
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 is assessing a newly admitted medical patient and notes there is a depression in the lower portion of the patients sternum. This patients health record should note the presence of what chest deformity?
- A. A barrel chest
- B. A funnel chest
- C. A pigeon chest
- D. Kyphoscoliosis
Correct Answer: B
Rationale: A funnel chest occurs when there is a depression in the lower portion of the sternum, and this may lead to compression of the heart and great vessels, resulting in murmurs. A barrel chest is characterized by an increase in the anteroposterior diameter of the thorax and is a result of overinflation of the lungs. A pigeon chest occurs as a result of displacement of the sternum and includes an increase in the anteroposterior diameter. Kyphoscoliosis, which is characterized by elevation of the scapula and a corresponding S-shaped spine, limits lung expansion within the thorax.
The nurse is caring for a patient who has been scheduled for a bronchoscopy. How should the nurse prepare the patient for this procedure?
- A. Administer a bolus of IV fluids.
- B. Arrange for the insertion of a peripherally inserted central catheter.
- C. Administer nebulized bronchodilators every 2 hours until the test.
- D. Withhold food and fluids for several hours before the test.
Correct Answer: D
Rationale: Food and fluids are withheld for 4 to 8 hours before the test to reduce the risk of aspiration when the cough reflex is blocked by anesthesia. IV fluids, bronchodilators, and a central line are unnecessary.
The nurse is caring for a patient with a lower respiratory tract infection. When planning a focused respiratory assessment, the nurse should know that this type of infection most often causes what?
- A. Impaired gas exchange
- B. Collapsed bronchial structures
- C. Necrosis of the alveoli
- D. Closed bronchial tree
Correct Answer: A
Rationale: The lower respiratory tract consists of the lungs, which contain the bronchial and alveolar structures needed for gas exchange. A lower respiratory tract infection does not collapse bronchial structures or close the bronchial tree. An infection does not cause necrosis of lung tissues.