Nokea
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.
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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.
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 admitting a patient to the emergency department who has sudden onset shortness of breath and is diagnosed with a possible pulmonary embolus. To confirm the diagnosis, which of the following diagnostic measures should the nurse anticipate?
- A. Positron emission tomography (PET) scan
- B. Chest x-ray
- C. Bronchoscopy
- D. Spiral computed tomography (CT) scan
Correct Answer: D
Rationale: Spiral CT scans are the most commonly used test to diagnose pulmonary emboli. A chest x-ray may be ordered but will not be diagnostic for a pulmonary embolus. Bronchoscopy is used to inspect for changes in the bronchial tree, not to assess for vascular changes. PET scans are most useful in determining the presence of malignancy.
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 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.