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The nurse is caring for a client with an exacerbation of COPD and scheduled for pulmonary function studies using a spirometer. Which client statement would the nurse clarify?
- A. My study is scheduled for 10 AM, several hours after I eat.'
- B. I brought comfortable clothes and shoes for the test.'
- C. I am ordered a bronchodilator to note lung improvement following use.'
- D. I will breathe in through my mouth and out through my nose.'
Correct Answer: D
Rationale: The nurse would clarify the client's statement of improper breathing technique. During a pulmonary function test using a spirometer, a nose clip prevents air from escaping through the client's nose when blowing into the spirometer. All other statements are correct.
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The nurse is caring for a client with hypoxemia of unknown cause. Which oxygen transport consideration(s) does the nurse identify as crucial to circulate oxygen in the body system? Select all that apply.
- A. Oxygen is dissolved.
- B. High blood pressure disrupts oxygen transport.
- C. Oxyhemoglobin circulates to the body tissue.
- D. All systemic oxygen is available for diffusion.
- E. Adequate red blood cells are needed for oxygen transport.
Correct Answer: A,C,E
Rationale: Oxygen transport occurs by dissolving oxygen in the water in the plasma and combining oxygen with red blood cells (oxyhemoglobin). Normal red blood cell count is needed for oxygen transport. High blood pressure does not disrupt transport unless there is disruption in perfusion via a bleeding or occlusion. Dissolved oxygen is the only form which can diffuse across cell membranes.
The nurse is caring for clients on the neurological unit. Which triad of neurological mechanisms does the nurse identify as most responsible when there is abnormality in ventilation control?
- A. Medulla oblongata, cerebellum, and heart rate
- B. Pons, cerebellum, and oxygen receptors
- C. Medulla oblongata, mitral valve, and central receptors
- D. Aortic arch, pons, and CO2 receptor sites
Correct Answer: D
Rationale: Several mechanisms control ventilation. The respiratory center in the medulla oblongata and pons control rate and depth of respirations. The central chemoreceptors in the medulla and peripheral chemoreceptors in the aortic arch also provide a mechanism for detecting abnormalities and signal changes to alter the pH and levels of oxygen in the blood. The other options have an incorrect piece of the triad.
A nurse is performing a physical assessment on a client who has a history of a respiratory infection. Which documentation, completed by the nurse, indicates improvement in an area of the lung affected by the infection?
- A. Lung fields documented as clear.
- B. Palpable vibrations over the chest wall when the client speaks.
- C. Decreased fremitus when the client feels the vibration in their chest.
- D. Dull sounds percussed over the lung tissue.
- E. Bronchial sounds heard only in the affected area.
Correct Answer: A
Rationale: To determine if the client's respiratory infection has resolved, the nurse should assess the client's normal respiratory status. Lungs will return to clear breath sounds. Palpable vibrations will be felt ,as they may be normal if there is no infection in the lungs. A client with consolidation of a lobe of the lung from pneumonia has increased tactile fremitus over that lobe. A decreased fremitus would indicate resolution of infection. Bronchial sounds will be noted over the upper lung fields. An increased fremitus is noted as the client speaks '99.' Dull percussed sounds indicate an area of consolidation or infection.
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.
The nurse is caring for a client in the immediate post-thoracentesis period. In which position is the client placed?
- A. In the supine position
- B. Lying on the unaffected side
- C. In the high Fowler's position
- D. Prone with a pillow under the head
Correct Answer: B
Rationale: Following a thoracentesis, the client remains on bed rest and typically lies on the unaffected side for at least 1 hour to promote expansion of the lung on the affected side. Lying flat in a supine position or prone does not promote expansion of the lung.