Nokea
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.
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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 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.
After the nurse has received change-of-shift report, which of the following patients should be assessed first?
- A. A patient with pneumonia who has crackles in the right lung base
- B. A patient with chronic obstructive pulmonary disease (COPD) and pulmonary function testing (PFT) that indicates low forced vital capacity
- C. A patient with possible lung cancer who has just returned after bronchoscopy
- D. A patient with hemoptysis and a 16-mm induration with tuberculin skin testing
Correct Answer: C
Rationale: Since the cough and gag are decreased after bronchoscopy, this patient should be assessed for airway maintenance. The other patients do not have clinical manifestations or procedures that require immediate assessment by the nurse.
The nurse is caring for a patient with a metabolic acidosis of unknown origin. Which of the following findings should the nurse expect based on this diagnosis?
- A. Intercostal retractions
- B. Kussmaul's respirations
- C. Low oxygen saturation (SpO2)
- D. Decrease in venous O2 pressure
Correct Answer: B
Rationale: Kussmaul's (deep and rapid) respirations are a compensatory mechanism for metabolic acidosis. Intercostal retractions, a low oxygen saturation rate, and a decrease in PO2 would not be caused by acidosis.
The nurse is assessing a patient with chronic obstructive pulmonary disease (COPD) with increasing dyspnea over the last 3 days. Which of the following findings is most important to report to the health care provider?
- A. Respirations are 36 breaths/minute.
- B. Anterior-posterior chest ratio is 1.1.
- C. Lung expansion is decreased bilaterally.
- D. Hyperresonance to percussion is present.
Correct Answer: A
Rationale: The increase in respiratory rate indicates respiratory distress and a need for rapid interventions such as administration of oxygen or medications. The other findings are common persistent changes occurring in patients with COPD.