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In addition to heart rate, blood pressure, respiratory rate, and temperature, the nurse needs to assess a patients arterial oxygen saturation (SaO2). What procedure will best accomplish this?
- A. Incentive spirometry
- B. Arterial blood gas (ABG) measurement
- C. Peak flow measurement
- D. Pulse oximetry
Correct Answer: D
Rationale: Pulse oximetry is a noninvasive procedure in which a small sensor is positioned over a pulsating vascular bed. It can be used during transport and causes the patient no discomfort. An incentive spirometer is used to assist the patient with deep breathing after surgery. ABG measurement can measure SaO2, but this is an invasive procedure that can be painful. Some patients with asthma use peak flow meters to measure levels of expired air.
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A patient on the medical unit has told the nurse that he is experiencing significant dyspnea, despite that he has not recently performed any physical activity. What assessment question should the nurse ask the patient while preparing to perform a physical assessment?
- A. On a scale from 1 to 10, how bad would you rate your shortness of breath?
- B. When was the last time you ate or drank anything?
- C. Are you feeling any nausea along with your shortness of breath?
- D. Do you think that some medication might help you catch your breath?
Correct Answer: A
Rationale: Gauging the severity of the patients dyspnea is an important part of the nursing process. Oral intake and nausea are much less important considerations. The nurse must perform assessment prior to interventions such as providing medication.
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.
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 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.
The nurse is caring for a patient who has a pleural effusion and who underwent a thoracoscopic procedure earlier in the morning. The nurse should prioritize assessment for which of the following?
- A. Sputum production
- B. Shortness of breath
- C. Throat discomfort
- D. Epistaxis
Correct Answer: B
Rationale: Follow-up care in the health care facility and at home involves monitoring the patient for shortness of breath (which might indicate a pneumothorax). All of the listed options are relevant assessment findings, but shortness of breath is the most serious complication.