Nokea
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.
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A patient is being treated for a pulmonary embolism and the medical nurse is aware that the patient suffered an acute disturbance in pulmonary perfusion. This involved an alteration in what aspect of normal physiology?
- A. Maintenance of constant osmotic pressure in the alveoli
- B. Maintenance of muscle tone in the diaphragm
- C. pH balance in the pulmonary veins and arteries
- D. Adequate flow of blood through the pulmonary circulation.
Correct Answer: D
Rationale: Pulmonary perfusion is the actual blood flow through the pulmonary circulation. Perfusion is not defined in terms of pH balance, muscle tone, or osmotic pressure.
A medical nurse has admitted a patient to the unit with a diagnosis of failure to thrive. The patient has developed a fever and cough, so a sputum specimen has been obtained. The nurse notes that the sputum is greenish and that there is a large quantity of it. The nurse notifies the patients physician because these symptoms are suggestive of what?
- A. Pneumothorax
- B. Lung tumors
- C. Infection
- D. Pulmonary edema
Correct Answer: C
Rationale: The nature of the sputum is often indicative of its cause. A profuse amount of purulent sputum (thick and yellow, green, or rust-colored) or a change in color of the sputum is a common sign of a bacterial infection. Pink-tinged mucoid sputum suggests a lung tumor. Profuse, frothy, pink material, often welling up into the throat, may indicate pulmonary edema. A pneumothorax does not result in copious, green sputum.
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 with chronic lung disease is undergoing lung function testing. What test result denotes the volume of air inspired and expired with a normal breath?
- A. Total lung capacity
- B. Forced vital capacity
- C. Tidal volume
- D. Residual volume
Correct Answer: C
Rationale: Tidal volume refers to the volume of air inspired and expired with a normal breath. Total lung capacity is the maximal amount of air the lungs and respiratory passages can hold after a forced inspiration. Forced vital capacity is vital capacity performed with a maximally forced expiration. Residual volume is the maximal amount of air left in the lung after a maximal expiration.
The nurse is caring for a patient who has just returned to the unit after a colon resection. The patient is showing signs of hypoxia. The nurse knows that this is probably caused by what?
- A. Nitrogen narcosis
- B. Infection
- C. Impaired diffusion
- D. Shunting
Correct Answer: D
Rationale: Shunting appears to be the main cause of hypoxia after thoracic or abdominal surgery and most types of respiratory failure. Impairment of normal diffusion is a less common cause. Infection would not likely be present at this early stage of recovery and nitrogen narcosis only occurs from breathing compressed air.