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The nurse is assessing the respiratory status of a patient who is experiencing an exacerbation of her emphysema symptoms. When preparing to auscultate, what breath sounds should the nurse anticipate?
- A. Absence of breath sounds
- B. Wheezing with discontinuous breath sounds
- C. Faint breath sounds with prolonged expiration
- D. Faint breath sounds with fine crackles
Correct Answer: C
Rationale: The breath sounds of the patient with emphysema are faint or often completely inaudible. When they are heard, the expiratory phase is prolonged.
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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.
The nurse is performing a respiratory assessment of an adult patient and is attempting to distinguish between vesicular, bronchovesicular, and bronchial (tubular) breath sounds. The nurse should distinguish between these normal breath sounds on what basis?
- A. Their location over a specific area of the lung
- B. The volume of the sounds
- C. Whether they are heard on inspiration or expiration
- D. Whether or not they are continuous breath sounds
Correct Answer: A
Rationale: Normal breath sounds are distinguished by their location over a specific area of the lung; they are identified as vesicular, bronchovesicular, and bronchial (tubular) breath sounds. Normal breath sounds are heard on both inspiration and expiration, and are continuous. They are not distinguished solely on the basis of volume.
A sputum study has been ordered for a patient who has developed coarse chest crackles and a fever. At what time should the nurse best collect the sample?
- A. Immediately after a meal
- B. First thing in the morning
- C. At bedtime
- D. After a period of exercise
Correct Answer: B
Rationale: Sputum samples ideally are obtained early in the morning before the patient has had anything to eat or drink.
The clinic nurse is caring for a patient who has been diagnosed with emphysema and who has just had a pulmonary function test (PFT) ordered. The patient asks, What exactly is this test for? What would be the nurses best response?
- A. A PFT measures how much air moves in and out of your lungs when you breathe.
- B. A PFT measures how much energy you get from the oxygen you breathe.
- C. A PFT measures how elastic your lungs are.
- D. A PFT measures whether oxygen and carbon dioxide move between your lungs and your blood.
Correct Answer: A
Rationale: PFTs are routinely used in patients with chronic respiratory disorders. They are performed to assess respiratory function and to determine the extent of dysfunction. Such tests include measurements of lung volumes, ventilatory function, and the mechanics of breathing, diffusion, and gas exchange. Lung elasticity and diffusion can often be implied from PFTs, but they are not directly assessed. Energy obtained from respiration is not measured directly.
The ED nurse is assessing a patient complaining of dyspnea. The nurse auscultates the patients chest and hears wheezing throughout the lung fields. What might this indicate?
- A. The patient has a narrowed airway.
- B. The patient has pneumonia.
- C. The patient needs physiotherapy.
- D. The patient has a hemothorax.
Correct Answer: A
Rationale: Wheezing is a high-pitched, musical sound that is often the major finding in a patient with bronchoconstriction or airway narrowing. Wheezing is not normally indicative of pneumonia or hemothorax. Wheezing does not indicate the need for physiotherapy.