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The nurse is caring for a patient who has been scheduled for a bronchoscopy. How should the nurse prepare the patient for this procedure?
- A. Administer a bolus of IV fluids.
- B. Arrange for the insertion of a peripherally inserted central catheter.
- C. Administer nebulized bronchodilators every 2 hours until the test.
- D. Withhold food and fluids for several hours before the test.
Correct Answer: D
Rationale: Food and fluids are withheld for 4 to 8 hours before the test to reduce the risk of aspiration when the cough reflex is blocked by anesthesia. IV fluids, bronchodilators, and a central line are unnecessary.
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A patient has been diagnosed with heart failure that has not yet responded to treatment. What breath sound should the nurse expect to assess on auscultation?
- A. Expiratory wheezes
- B. Inspiratory wheezes
- C. Rhonchi
- D. Crackles
Correct Answer: D
Rationale: Crackles reflect underlying inflammation or congestion and are often present in such conditions as pneumonia, bronchitis, and congestive heart failure. Rhonchi and wheezes are associated with airway obstruction, which is not a part of the pathophysiology of heart failure.
A patient is scheduled to have excess pleural fluid aspirated with a needle in order to relieve her dyspnea. The patient inquires about the normal function of pleural fluid. What should the nurse describe?
- A. It allows for full expansion of the lungs within the thoracic cavity.
- B. It prevents the lungs from collapsing within the thoracic cavity.
- C. It limits lung expansion within the thoracic cavity.
- D. It lubricates the movement of the thorax and lungs.
Correct Answer: D
Rationale: The visceral pleura cover the lungs; the parietal pleura line the thorax. The visceral and parietal pleura and the small amount of pleural fluid between these two membranes serve to lubricate the thorax and lungs and permit smooth motion of the lungs within the thoracic cavity with each breath. The pleura do not allow full expansion of the lungs, prevent the lungs from collapsing, or limit lung expansion within the thoracic cavity.
The nurse is caring for a patient admitted with an acute exacerbation of chronic obstructive pulmonary disease. During assessment, the nurse finds that the patient is experiencing increased dyspnea. What is the most accurate measurement of the concentration of oxygen in the patients blood?
- A. A capillary blood sample
- B. Pulse oximetry
- C. An arterial blood gas (ABG) study
- D. A complete blood count (CBC)
Correct Answer: C
Rationale: The arterial oxygen tension (partial pressure or PaO2) indicates the degree of oxygenation of the blood, and the arterial carbon dioxide tension (partial pressure or PaCO2) indicates the adequacy of alveolar ventilation. ABG studies aid in assessing the ability of the lungs to provide adequate oxygen and remove carbon dioxide and the ability of the kidneys to reabsorb or excrete bicarbonate ions to maintain normal body pH. Capillary blood samples are venous blood, not arterial blood, so they are not as accurate as an ABG. Pulse oximetry is a useful clinical tool but does not replace ABG measurement, because it is not as accurate. A CBC does not indicate the concentration of oxygen.
The nurse is assessing a patient who frequently coughs after eating or drinking. How should the nurse best follow up this assessment finding?
- A. Obtain a sputum sample.
- B. Perform a swallowing assessment.
- C. Inspect the patients tongue and mouth.
- D. Assess the patients nutritional status.
Correct Answer: B
Rationale: Coughing after food intake may indicate aspiration of material into the tracheobronchial tree; a swallowing assessment is thus indicated. Obtaining a sputum sample is relevant in cases of suspected infection. The status of the patients tongue, mouth, and nutrition is not directly relevant to the problem of aspiration.
A medical nurse has admitted a patient to the unit with a diagnosis of failure to thrive. The patient has developed a fever and cough, so a sputum specimen has been obtained. The nurse notes that the sputum is greenish and that there is a large quantity of it. The nurse notifies the patients physician because these symptoms are suggestive of what?
- A. Pneumothorax
- B. Lung tumors
- C. Infection
- D. Pulmonary edema
Correct Answer: C
Rationale: The nature of the sputum is often indicative of its cause. A profuse amount of purulent sputum (thick and yellow, green, or rust-colored) or a change in color of the sputum is a common sign of a bacterial infection. Pink-tinged mucoid sputum suggests a lung tumor. Profuse, frothy, pink material, often welling up into the throat, may indicate pulmonary edema. A pneumothorax does not result in copious, green sputum.