Nokea
The nurse is performing a respiratory assessment of an adult patient and is attempting to distinguish between vesicular, bronchovesicular, and bronchial (tubular) breath sounds. The nurse should distinguish between these normal breath sounds on what basis?
- A. Their location over a specific area of the lung
- B. The volume of the sounds
- C. Whether they are heard on inspiration or expiration
- D. Whether or not they are continuous breath sounds
Correct Answer: A
Rationale: Normal breath sounds are distinguished by their location over a specific area of the lung; they are identified as vesicular, bronchovesicular, and bronchial (tubular) breath sounds. Normal breath sounds are heard on both inspiration and expiration, and are continuous. They are not distinguished solely on the basis of volume.
You may also like to solve these questions
The nurse is caring for a patient with a lower respiratory tract infection. When planning a focused respiratory assessment, the nurse should know that this type of infection most often causes what?
- A. Impaired gas exchange
- B. Collapsed bronchial structures
- C. Necrosis of the alveoli
- D. Closed bronchial tree
Correct Answer: A
Rationale: The lower respiratory tract consists of the lungs, which contain the bronchial and alveolar structures needed for gas exchange. A lower respiratory tract infection does not collapse bronchial structures or close the bronchial tree. An infection does not cause necrosis of lung tissues.
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.
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.
A patient has been diagnosed with pulmonary hypertension, in which the capillaries in the alveoli are squeezed excessively. The nurse should recognize a disturbance in what aspect of normal respiratory function?
- A. Acid-base balance
- B. Perfusion
- C. Diffusion
- D. Ventilation
Correct Answer: B
Rationale: Perfusion is influenced by alveolar pressure. The pulmonary capillaries are sandwiched between adjacent alveoli and, if the alveolar pressure is sufficiently high, the capillaries are squeezed. This does not constitute a disturbance in ventilation (air movement), diffusion (gas exchange), or acid-base balance.
The nurse is caring for a patient who has returned to the unit following a bronchoscopy. The patient is asking for something to drink. Which criterion will determine when the nurse should allow the patient to drink fluids?
- A. Presence of a cough and gag reflex
- B. Absence of nausea
- C. Ability to demonstrate deep inspiration
- D. Oxygen saturation of 92%
Correct Answer: A
Rationale: After the procedure, it is important that the patient takes nothing by mouth until the cough reflex returns because the preoperative sedation and local anesthesia impair the protective laryngeal reflex and swallowing for several hours. Deep inspiration, adequate oxygen saturation levels, and absence of nausea do not indicate that oral intake is safe from the risk of aspiration.