Nokea
The nurse is caring for a patient with respiratory disease and observes that the patient's SpO2 drops from 92% to 88% while the patient is ambulating in the hallway. Which of the following actions should the nurse take next?
- A. Notify the health care provider.
- B. Document the response to exercise.
- C. Administer the PRN supplemental O2.
- D. Encourage the patient to pace activity.
Correct Answer: C
Rationale: The drop in SpO2 to 88% indicates that the patient is hypoxic and needs supplemental oxygen when exercising. The other actions also are appropriate, but the first action should be to correct the hypoxemia.
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Which of the following actions should the nurse plan to take for a patient who is scheduled for pulmonary function testing (PFT)?
- A. Explain reasons for NPO status.
- B. Administer sedative drug before PFT.
- C. Assess pulse and BP after the procedure.
- D. Teach deep inhalation and forceful exhalation.
Correct Answer: D
Rationale: For PFT, the patient should inhale deeply and exhale as long, hard, and fast as possible. The other actions are not needed with PFT.
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.
Which of the following respiratory assessments are not normal? (Select all that apply.)
- A. Respirations 23 breaths/minute
- B. Outward movement of abdomen during inspiration
- C. Increase in vibrations with tactile fremitus
- D. Tripod position
- E. Symmetrical chest expansion
Correct Answer: A,C,D
Rationale: Respirations greater than 20 breaths/minute indicate tachypnea. Tactile fremitus is often increased in pneumonia and pulmonary edema. The tripod position is assumed in patients with COPD, asthma in exacerbation and pulmonary edema. Outward movement of the abdomen during inspiration is normal. Symmetrical chest expansion is normal.
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.
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.