Nokea
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.
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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.
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.
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.
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 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.