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The student nurse is learning breath sounds while listening to a client in the physician's office. An experienced nurse is assisting and notes air movement over the trachea to the upper lungs. The air movement is noted equally on inspiration and expiration. Which breath sounds would the nurse document?
- A. Abnormal vesicular sounds
- B. Normal bronchial sounds
- C. Normal bronchovesicular sounds
- D. Abnormal bronchial sounds
Correct Answer: C
Rationale: Air movement over the trachea and upper lungs is a normal finding for bronchovesicular sounds. The air movement is noted equally on inspiration and expiration. The other choices do not match the description.
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Including clients with a history of respiratory issues, for which diagnostic stud(ies) would the nurse screen the client for an allergy to contrast medium prior to testing?
- A. Lung scan
- B. Chest x-ray
- C. Pulmonary angiography
- D. Bronchoscopy
- E. Pulmonary function test
- F. Sputum culture
Correct Answer: A,C
Rationale: The nurse must be well educated in screening clients before diagnostic procedures, which include contrast medium for an allergy to iodine. A lung scan and pulmonary angiography both require contrast medium. A chest x-ray, bronchoscopy, sputum culture test, and pulmonary functions test do not require contrast medium.
The nurse is caring for a client with a decrease in airway diameter causing airway resistance. The client experiences coughing and mucus production. On lung assessment, which adventitious breath sounds are anticipated?
- A. Crackles
- B. Sonorous wheezes
- C. Rubs
- D. Sibilant wheezes
Correct Answer: D
Rationale: A decrease in airway diameter, such as in asthma, produces breath sounds of wheezes. Wheezes may be sibilant (hissing or whistling) or sonorous (full and deep). Sibilant wheezes (formerly called wheezes) are continuous musical sounds that can be heard during inspiration and expiration. They result from air passing through narrowed or partially obstructed air passages and are heard in clients with increased secretions. Sonorous wheezes (formerly called rhonchi) are lower pitched and are heard in the trachea and bronchi. Sonorous wheezes are coarse, rattling sounds similar to snoring usually caused by secretion in the bronchial tree. Crackles, also called rales, are crackling or rattling sounds signifying fluid or exudate in the lung fields. Rubs are secretions that can be heard in the large airway.
The client is returning from the operating room following a bronchoscopy. Which action, performed by the nursing assistant, would the nurse stop if began prior to nursing assessment?
- A. The nursing assistant is assisting the client to a semi-Fowler's position.
- B. The nursing assistant is assisting the client to the side of the bed to use a urinal.
- C. The nursing assistant is pouring a glass of water to wet the client's mouth.
- D. The nursing assistant is asking a question requiring a verbal response.
Correct Answer: C
Rationale: When completing a procedure which sends a scope down the throat, the gag reflex is anesthetized to reduce discomfort. Upon returning to the nursing unit, the gag reflex must be assessed before providing any food or fluids to the client. The client may need assistance following the procedure for activity and ambulation but this is not restricted in the post-procedure period.
The nurse is caring for a client who states, 'I am really worried about the thoracentesis. I know I won't be able to sleep tonight.' Which statement is most helpful to the client at this time?
- A. Tell me what you are worried about.'
- B. Is there something that I can help you with?'
- C. Is there someone that you would like me to call to be with you?'
- D. The physician will see you before the procedure and can answer any questions.'
Correct Answer: A
Rationale: A thoracentesis is performed by inserting a needle into the wall under local anesthesia. The thoracentesis is often done at the bedside. Providing support to the client before, during, and after the treatment is a nursing responsibility. When the client expresses being worried, asking an open-ended question promotes communication and is most therapeutic. Asking if there is something that a nurse can do is a closed-ended question. Asking about calling someone to be with the client makes the nurse seem uninterested. Talking with the physician closes communication with the nurse, making the nurse seem uninterested.
The nurse is analyzing a client's blood pH of 7.1. Which symptom would indicate that the client's body is working to stabilize?
- A. Respirations are increasing.
- B. Urine output is decreased.
- C. Heart rate is regular.
- D. WBC count is within normal limits.
Correct Answer: A
Rationale: Increased CO2 mechanism, which is present in body fluids primarily as carbonic acid, causes the pH to decrease below 7.4. As a homeostatic mechanism to normalize pH, the lungs eliminate carbonic acid by blowing off more CO2. Respirations increase to normalize pH. None of the other symptoms note a reflection of stabilizing blood pH.