Nokea
The nurse is observing a student who is listening to a patient's lungs. Which of the following actions by the student indicates a need to review respiratory assessment skills?
- A. The student compares breath sounds from side to side.
- B. The student listens only over the posterior part of the chest.
- C. The student places the stethoscope over the scapulae and then auscultates.
- D. The student starts at the base of the posterior lung and moves to the apices.
Correct Answer: C
Rationale: The stethoscope should be placed over lung tissue, not over bony structures. Breath sounds should be compared from side to side. The techniques of starting at the lung base and then moving toward the apices and listening only over the posterior chest are acceptable.
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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.
Which of the following pH values is abnormal for a pH when assessing blood results of a mixed venous blood sample?
- A. 7.31
- B. 7.35
- C. 7.4
- D. 7.42
Correct Answer: D
Rationale: The normal pH of a mixed venous sample is 7.31-7.41. The normal pH of an arterial blood sample is 7.35-7.45.
The nurse has just received arterial blood gas (ABG) results on four patients. Which of the following results is considered normal?
- A. pH 7.32, PaO2 85 mm Hg, PaCO2 55 mm Hg, and O2 saturation 90%
- B. pH 7.38, PaO2 75 mm Hg, PaCO2 40 mm Hg, and O2 saturation 95%
- C. pH 7.42, PaO2 80 mm Hg, PaCO2 33 mm Hg, and O2 saturation 98%
- D. pH 7.52, PaO2 90 mm Hg, PaCO2 30 mm Hg, and O2 saturation 94%
Correct Answer: B
Rationale: These ABGs indicate normal values: pH 7.35-7.45, PaO2 75-100 mm Hg, PaCO2 35-45 mm Hg, and O2 saturation 95-100%.
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 performing an assessment of the patient's respiratory system. Which of the following parameters is the nurse assessing when using the following illustrated technique?
- A. Bronchophony
- B. Chest expansion
- C. Accessory muscle use
- D. Diaphragmatic excursion
Correct Answer: B
Rationale: Symmetrical chest expansion is confirmed by placement of the hands over the anterior or posterior chest at the same level, observing to confirm is hands and thumbs move equally on both sides with inspiration and expiration.