Nokea
The nurse is auscultaining a patient's lungs and hears short, high-pitched sounds during exhalation in the lower 1/3 of both lungs. Which of the following information should the nurse document?
- A. Expiratory crackles at the bases
- B. Expiratory wheezes in both lung bases
- C. Abnormal lung sounds in the bases of both lungs
- D. Pleural friction rub in the right and left lower lobes
Correct Answer: B
Rationale: Wheezes are high-pitched sounds. In this case they are heard during the expiratory phase of the respiratory cycle. Abnormal breath sounds are either bronchial or bronchovescular sounds heard in the peripheral lung fields. Crackles are low-pitched, 'bubbling' sounds. Pleural friction rubs are grating sounds that are usually heard during both inspiration and expiration.
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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 preparing a patient with a right-sided pleural effusion for a thoracentesis. Which of the following positions should the nurse position the patient?
- A. Supine with the head of the bed elevated 45 degrees
- B. In the Trendelenburg position with both arms extended
- C. On the left side with the right arm extended above the head
- D. Sitting upright with the arms supported on an over bed table
Correct Answer: D
Rationale: The upright position with the arms supported increases lung expansion, allows fluid to collect at the lung bases, and expands the intercostal space so that access to the pleural space is easier. The other positions would increase the work of breathing for the patient and make it more difficult for the health care provider performing the thoracentesis.
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.
The nurse is assessing a patient with chronic obstructive pulmonary disease (COPD) with increasing dyspnea over the last 3 days. Which of the following findings is most important to report to the health care provider?
- A. Respirations are 36 breaths/minute.
- B. Anterior-posterior chest ratio is 1.1.
- C. Lung expansion is decreased bilaterally.
- D. Hyperresonance to percussion is present.
Correct Answer: A
Rationale: The increase in respiratory rate indicates respiratory distress and a need for rapid interventions such as administration of oxygen or medications. The other findings are common persistent changes occurring in patients with COPD.
Which of the following pH values is abnormal for a pH when assessing blood results of a mixed venous blood sample?
- A. 7.31
- B. 7.35
- C. 7.4
- D. 7.42
Correct Answer: D
Rationale: The normal pH of a mixed venous sample is 7.31-7.41. The normal pH of an arterial blood sample is 7.35-7.45.