Nokea
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.
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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 respiratory assessments are not normal? (Select all that apply.)
- A. Respirations 23 breaths/minute
- B. Outward movement of abdomen during inspiration
- C. Increase in vibrations with tactile fremitus
- D. Tripod position
- E. Symmetrical chest expansion
Correct Answer: A,C,D
Rationale: Respirations greater than 20 breaths/minute indicate tachypnea. Tactile fremitus is often increased in pneumonia and pulmonary edema. The tripod position is assumed in patients with COPD, asthma in exacerbation and pulmonary edema. Outward movement of the abdomen during inspiration is normal. Symmetrical chest expansion is normal.
The nurse is caring for a patient with respiratory disease and observes that the patient's SpO2 drops from 92% to 88% while the patient is ambulating in the hallway. Which of the following actions should the nurse take next?
- A. Notify the health care provider.
- B. Document the response to exercise.
- C. Administer the PRN supplemental O2.
- D. Encourage the patient to pace activity.
Correct Answer: C
Rationale: The drop in SpO2 to 88% indicates that the patient is hypoxic and needs supplemental oxygen when exercising. The other actions also are appropriate, but the first action should be to correct the hypoxemia.
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.
The nurse has just received arterial blood gas (ABG) results on four patients. Which of the following results is considered normal?
- A. pH 7.32, PaO2 85 mm Hg, PaCO2 55 mm Hg, and O2 saturation 90%
- B. pH 7.38, PaO2 75 mm Hg, PaCO2 40 mm Hg, and O2 saturation 95%
- C. pH 7.42, PaO2 80 mm Hg, PaCO2 33 mm Hg, and O2 saturation 98%
- D. pH 7.52, PaO2 90 mm Hg, PaCO2 30 mm Hg, and O2 saturation 94%
Correct Answer: B
Rationale: These ABGs indicate normal values: pH 7.35-7.45, PaO2 75-100 mm Hg, PaCO2 35-45 mm Hg, and O2 saturation 95-100%.