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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.
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The nurse is admitting a patient who is hypothermic with a O2 saturation of 96%. Which of the following actions should the nurse take next?
- A. Initiate rewarming of the patient.
- B. Complete a head-to-toe assessment.
- C. Obtain arterial blood gases (ABGs).
- D. Place the patient on high-flow oxygen.
Correct Answer: D
Rationale: Although the O2 saturation is adequate, the left shift in the oxyhemoglobin dissociation curve will decrease the amount of oxygen delivered to tissues, so high oxygen concentrations should be given until the patient is normothermic. The other actions also are appropriate, but the initial action should be to administer oxygen.
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 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.
The nurse is reviewing a patient's laboratory results and identifies which of the following values as a normal tidal volume?
- A. 100 mL
- B. 250 mL
- C. 500 mL
- D. 1000 mL
Correct Answer: C
Rationale: The normal tidal volume is 500 mL.
The nurse is admitting a patient with acute shortness of breath. Which of the following actions should the nurse take during the initial assessment of the patient?
- A. Complete a full physical examination to determine the systemic effect of the respiratory distress.
- B. Obtain a comprehensive health history to determine the extent of any prior respiratory condition.
- C. Delay the physical assessment and ask family members about any history of respiratory conditions.
- D. Perform a respiratory system assessment and ask specific questions about this episode of respiratory distress.
Correct Answer: D
Rationale: When a patient has severe respiratory distress, only information pertinent to the current episode is obtained, and a more thorough assessment is deferred until later. Obtaining a comprehensive health history or full physical examination is unnecessary until the acute distress has resolved. A focused physical assessment should be done rapidly to help determine the cause of the distress and suggest treatment. Although family members may know about the patient's history of medical problems, the patient is the best informant for these data.