Nokea
After the nurse has received change-of-shift report, which of the following patients should be assessed first?
- A. A patient with pneumonia who has crackles in the right lung base
- B. A patient with chronic obstructive pulmonary disease (COPD) and pulmonary function testing (PFT) that indicates low forced vital capacity
- C. A patient with possible lung cancer who has just returned after bronchoscopy
- D. A patient with hemoptysis and a 16-mm induration with tuberculin skin testing
Correct Answer: C
Rationale: Since the cough and gag are decreased after bronchoscopy, this patient should be assessed for airway maintenance. The other patients do not have clinical manifestations or procedures that require immediate assessment by the nurse.
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The nurse is auscultaining a patient's lungs and hears short, high-pitched sounds during exhalation in the lower 1/3 of both lungs. Which of the following information should the nurse document?
- A. Expiratory crackles at the bases
- B. Expiratory wheezes in both lung bases
- C. Abnormal lung sounds in the bases of both lungs
- D. Pleural friction rub in the right and left lower lobes
Correct Answer: B
Rationale: Wheezes are high-pitched sounds. In this case they are heard during the expiratory phase of the respiratory cycle. Abnormal breath sounds are either bronchial or bronchovescular sounds heard in the peripheral lung fields. Crackles are low-pitched, 'bubbling' sounds. Pleural friction rubs are grating sounds that are usually heard during both inspiration and expiration.
The nurse is analyzing the results of a patient's arterial blood gases (ABGs). Which of the following findings require the most immediate action?
- A. The arterial oxygen saturation (SaO2) is 92%.
- B. The partial pressure of oxygen in arterial blood (PaO2) is 59 mm Hg.
- C. The partial pressure of CO2 in arterial blood (PaCO2) is 31 mm Hg.
- D. The bicarbonate level (HCO3-) is 29 mmol/L.
Correct Answer: B
Rationale: All the values are abnormal, but the low PaO2 indicates that the patient is at the point on the oxyhemoglobin dissociation curve where a small change in the PaO2 will cause a large drop in the O2 saturation and a decrease in tissue oxygenation. The nurse should intervene immediately to improve the patient's oxygenation.
Which of the following actions should the nurse plan to take for a patient who is scheduled for pulmonary function testing (PFT)?
- A. Explain reasons for NPO status.
- B. Administer sedative drug before PFT.
- C. Assess pulse and BP after the procedure.
- D. Teach deep inhalation and forceful exhalation.
Correct Answer: D
Rationale: For PFT, the patient should inhale deeply and exhale as long, hard, and fast as possible. The other actions are not needed with PFT.
The nurse is assessing the respiratory system of an older-adult patient. Which of the following findings indicate that the nurse should take immediate action?
- A. The chest appears barrel shaped.
- B. The patient has a weak cough effort.
- C. Crackles are heard from the lung bases to the midline.
- D. Hyperresonance is present across both sides of the chest.
Correct Answer: C
Rationale: Crackles in the lower half of the lungs indicate that the patient may have an acute problem such as heart failure. The nurse should immediately accomplish further assessments, such as oxygen saturation, and notify the health care provider. A barrel-shaped chest, hyper-resonance to percussion, and a weak cough effort are associated with aging. Further evaluation may be needed, but immediate action is not indicated.
The nurse is reviewing a patient's laboratory results and identifies which of the following values as a normal tidal volume?
- A. 100 mL
- B. 250 mL
- C. 500 mL
- D. 1000 mL
Correct Answer: C
Rationale: The normal tidal volume is 500 mL.