Nokea
The nurse is caring for a client with a decrease in airway diameter causing airway resistance. The client experiences coughing and mucus production. On lung assessment, which adventitious breath sounds are anticipated?
- A. Crackles
- B. Sonorous wheezes
- C. Rubs
- D. Sibilant wheezes
Correct Answer: D
Rationale: A decrease in airway diameter, such as in asthma, produces breath sounds of wheezes. Wheezes may be sibilant (hissing or whistling) or sonorous (full and deep). Sibilant wheezes (formerly called wheezes) are continuous musical sounds that can be heard during inspiration and expiration. They result from air passing through narrowed or partially obstructed air passages and are heard in clients with increased secretions. Sonorous wheezes (formerly called rhonchi) are lower pitched and are heard in the trachea and bronchi. Sonorous wheezes are coarse, rattling sounds similar to snoring usually caused by secretion in the bronchial tree. Crackles, also called rales, are crackling or rattling sounds signifying fluid or exudate in the lung fields. Rubs are secretions that can be heard in the large airway.
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What would the instructor tell the students purulent fluid indicates?
- A. Cancer
- B. Infection
- C. Inflammation
- D. Heart failure
Correct Answer: B
Rationale: A small amount of fluid lies between the visceral and parietal pleurae. When excess fluid or air accumulates, the physician aspirates it from the pleural space by inserting a needle into the chest wall. This procedure, called thoracentesis, is performed with local anesthesia. Thoracentesis also may be used to obtain a sample of pleural fluid or a biopsy specimen from the pleural wall for diagnostic purposes such as a culture, sensitivity, or microscopic examination. Purulent fluid is the recommended diagnosis for infection. Serous fluid may be associated with cancer, inflammatory conditions, or heart failure.
A nurse is instructing the client on the normal sensations that can occur when contrast medium is infused during pulmonary angiography. Which client statement demonstrates an understanding of the teaching?
- A. I will feel a dull pain when the catheter is introduced.'
- B. I will feel light-headed when the contrast medium is introduced.'
- C. I will feel waves of nausea throughout the procedure.'
- D. I will feel warm and may have chest pain'
Correct Answer: D
Rationale: During a pulmonary angiography, a contrast medium is injected into the femoral circulation. When the medium is infused, the client will feel warm and flushed, with a possibility of chest pain. The client will feel pressure when the catheter is inserted. The client does not typically feel light-headed or nauseated during this procedure.
A nurse is obtaining a health history from a client who reports hemoptysis for the past 2 months. The client reports occasional dyspnea. Which imaging study, ordered by the physician, will view the thoracic cavity while in motion?
- A. Fluoroscopy
- B. Chest x-ray
- C. Magnetic resonance imaging (MRI)
- D. Computed tomography (CT) scan
Correct Answer: A
Rationale: Fluoroscopy enables the physician to view the thoracic cavity with all of its contents in motion. A fluoroscopy more precisely diagnoses the location of a tumor or lesion. An x-ray shows the size, shape, and position of the lungs. An MRI and CT produce axial views of the lungs.
The nurse is analyzing a client's blood pH of 7.1. Which symptom would indicate that the client's body is working to stabilize?
- A. Respirations are increasing.
- B. Urine output is decreased.
- C. Heart rate is regular.
- D. WBC count is within normal limits.
Correct Answer: A
Rationale: Increased CO2 mechanism, which is present in body fluids primarily as carbonic acid, causes the pH to decrease below 7.4. As a homeostatic mechanism to normalize pH, the lungs eliminate carbonic acid by blowing off more CO2. Respirations increase to normalize pH. None of the other symptoms note a reflection of stabilizing blood pH.
The nurse is caring for a client who states, 'I am really worried about the thoracentesis. I know I won't be able to sleep tonight.' Which statement is most helpful to the client at this time?
- A. Tell me what you are worried about.'
- B. Is there something that I can help you with?'
- C. Is there someone that you would like me to call to be with you?'
- D. The physician will see you before the procedure and can answer any questions.'
Correct Answer: A
Rationale: A thoracentesis is performed by inserting a needle into the wall under local anesthesia. The thoracentesis is often done at the bedside. Providing support to the client before, during, and after the treatment is a nursing responsibility. When the client expresses being worried, asking an open-ended question promotes communication and is most therapeutic. Asking if there is something that a nurse can do is a closed-ended question. Asking about calling someone to be with the client makes the nurse seem uninterested. Talking with the physician closes communication with the nurse, making the nurse seem uninterested.