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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.
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The nurse is observing a student who is listening to a patient's lungs. Which of the following actions by the student indicates a need to review respiratory assessment skills?
- A. The student compares breath sounds from side to side.
- B. The student listens only over the posterior part of the chest.
- C. The student places the stethoscope over the scapulae and then auscultates.
- D. The student starts at the base of the posterior lung and moves to the apices.
Correct Answer: C
Rationale: The stethoscope should be placed over lung tissue, not over bony structures. Breath sounds should be compared from side to side. The techniques of starting at the lung base and then moving toward the apices and listening only over the posterior chest are acceptable.
The nurse is auscultating a patient's chest while the patient takes a deep breath and hears loud, high-pitched, 'blowing' sounds in both lung bases. Which of the following information should the nurse document?
- A. Normal sounds
- B. Vesicular sounds
- C. Abnormal sounds
- D. Adventitious sounds
Correct Answer: C
Rationale: The description indicates that the nurse hears bronchial breath sounds that are abnormal when heard in the peripheral lung fields. Adventitious sounds are extra breath sounds such as crackles, wheezes, rhonchi, and friction rubs. Vesicular sounds are low-pitched, soft sounds heard over all lung areas except the major bronchi.
The nurse is caring for a patient with respiratory disease and observes that the patient's SpO2 drops from 92% to 88% while the patient is ambulating in the hallway. Which of the following actions should the nurse take next?
- A. Notify the health care provider.
- B. Document the response to exercise.
- C. Administer the PRN supplemental O2.
- D. Encourage the patient to pace activity.
Correct Answer: C
Rationale: The drop in SpO2 to 88% indicates that the patient is hypoxic and needs supplemental oxygen when exercising. The other actions also are appropriate, but the first action should be to correct the hypoxemia.
Which of the following respiratory assessments are not normal? (Select all that apply.)
- A. Respirations 23 breaths/minute
- B. Outward movement of abdomen during inspiration
- C. Increase in vibrations with tactile fremitus
- D. Tripod position
- E. Symmetrical chest expansion
Correct Answer: A,C,D
Rationale: Respirations greater than 20 breaths/minute indicate tachypnea. Tactile fremitus is often increased in pneumonia and pulmonary edema. The tripod position is assumed in patients with COPD, asthma in exacerbation and pulmonary edema. Outward movement of the abdomen during inspiration is normal. Symmetrical chest expansion is normal.
The nurse is admitting a patient who is hypothermic with a O2 saturation of 96%. Which of the following actions should the nurse take next?
- A. Initiate rewarming of the patient.
- B. Complete a head-to-toe assessment.
- C. Obtain arterial blood gases (ABGs).
- D. Place the patient on high-flow oxygen.
Correct Answer: D
Rationale: Although the O2 saturation is adequate, the left shift in the oxyhemoglobin dissociation curve will decrease the amount of oxygen delivered to tissues, so high oxygen concentrations should be given until the patient is normothermic. The other actions also are appropriate, but the initial action should be to administer oxygen.