Nokea
The nurse is admitting a patient with acute shortness of breath. Which of the following actions should the nurse take during the initial assessment of the patient?
- A. Complete a full physical examination to determine the systemic effect of the respiratory distress.
- B. Obtain a comprehensive health history to determine the extent of any prior respiratory condition.
- C. Delay the physical assessment and ask family members about any history of respiratory conditions.
- D. Perform a respiratory system assessment and ask specific questions about this episode of respiratory distress.
Correct Answer: D
Rationale: When a patient has severe respiratory distress, only information pertinent to the current episode is obtained, and a more thorough assessment is deferred until later. Obtaining a comprehensive health history or full physical examination is unnecessary until the acute distress has resolved. A focused physical assessment should be done rapidly to help determine the cause of the distress and suggest treatment. Although family members may know about the patient's history of medical problems, the patient is the best informant for these data.
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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.
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 palpating the posterior chest of a patient while the patient says '99' and notes that no vibration is felt. Which of the following information should the nurse document?
- A. Diminished expansion
- B. Dullness to percussion
- C. Absent tactile fremitus
- D. Decreased breath sounds
Correct Answer: C
Rationale: To assess for tactile fremitus, the nurse should use the palms of the hands to assess for vibration when the patient repeats a word or phrase such as '99.' Different techniques are used to assess for dullness to percussion, decreased breath sounds, and diminished expansion.
The nurse is caring for a patient with a persistent cough who has had a bronchoscopy. Which of the following actions should the nurse include in the nursing care plan after the procedure?
- A. Elevate the head of the bed to 80-90 degrees.
- B. Keep the patient NPO until the gag reflex returns.
- C. Place on bed rest for at least 4 hours post-bronchoscopy.
- D. Notify the health care provider about blood-tinged mucus.
Correct Answer: B
Rationale: Because a local anaesthetic is used to suppress the gag or cough reflexes during bronchoscopy, the nurse should monitor for the return of these reflexes before allowing the patient to take oral fluids or food. Blood-tinged mucus is not uncommon after bronchoscopy. The patient does not need to be on bed rest, and the head of the bed does not need to be in the high Fowler's position.