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The nurse assessing an 11 year old who is having an asthma attack expects to hear which adventitious sounds?
- A. Friction rub.
- B. Expiratory wheezes
- C. Crackles.
- D. Absent breath sounds.
Correct Answer: B
Rationale: The narrowed bronchioles characteristic of an asthma attack would produce wheezes, which are high-pitched whistling sounds.
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The older adult patient with long-term emphysema reports experiencing a sharp pleuritic pain after a severe period of coughing. The patient's heart rate and respiratory rate have increased. Auscultation reveals no breath sounds on the left side. These are signs and symptoms of which condition?
- A. Pulmonary embolus
- B. Spontaneous pneumothorax
- C. Early signs of unilateral pneumonia
- D. An attack of asthma
Correct Answer: B
Rationale: Spontaneous pneumothorax can be caused by a ruptured bleb in a patient with long-term emphysema. The disorder causes chest pain, dyspnea, and anxiety associated with air hunger.
A patient, age 22, is admitted with acute asthma. The patient shows a pulse oximetry level of SaO2 of 82%. How should the nurse interpret this?
- A. Only 82% of the red blood cells are able to use oxygen.
- B. There is only 82% of oxygen bound to the hemoglobin compared with the amount available.
- C. Eighteen percent of oxygen is not dissolved in the blood.
- D. The muscular respiratory effort is only 18% effective.
Correct Answer: B
Rationale: An SaO2 of 82% indicates that only 82% of the available oxygen is bound to the hemoglobin.
Which patient assessment indicates the most severe respiratory distress?
- A. Nasal flaring, symmetrical chest wall expansion, SaO2 88%
- B. Abdominal breathing, SaO2 97%
- C. Substernal retraction, SaO2 84%
- D. Substernal retraction, SaO2 90%
Correct Answer: C
Rationale: Observe the patient's facial expressions and signs of respiratory distress, such as flaring nostrils, substernal or clavicular retractions, asymmetrical chest wall expansion, and abdominal breathing. The lower the SaO2, the more severe the respiratory distress.
Which event happens when there is a decrease in the oxygen level in the blood?
- A. Pituitary stimulates the respiratory system to increase respiratory rate.
- B. The alveoli diffuse more oxygen into the blood.
- C. Chemoreceptors in the carotid body and aortic body stimulate the respiratory centers to modify respiratory rates.
- D. The parietal pleura increases the negative pressure.
Correct Answer: C
Rationale: The chemoreceptors in the carotid bodies and the aortic bodies send a message to the respiratory centers to modify respirations.
A patient comes to the health nurse at the workplace with epistaxis. The patient reports frequent nosebleeds that have usually been controlled without intervention. Which assessment would be the most helpful after the nurse has stopped the bleeding?
- A. Obtain a blood pressure.
- B. Record the approximate amount of blood lost.
- C. Inquire about a headache.
- D. Record the last episode of epistaxis.
Correct Answer: A
Rationale: Check the blood pressure for hypotension to assess for hypovolemic shock. Adults can lose as much as 1 L of blood in an hour with heavy epistaxis. In addition, epistaxis can be a complication of untreated hypertension.