Nokea
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.
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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.
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 analyzing the results of a patient's arterial blood gases (ABGs). Which of the following findings require the most immediate action?
- A. The arterial oxygen saturation (SaO2) is 92%.
- B. The partial pressure of oxygen in arterial blood (PaO2) is 59 mm Hg.
- C. The partial pressure of CO2 in arterial blood (PaCO2) is 31 mm Hg.
- D. The bicarbonate level (HCO3-) is 29 mmol/L.
Correct Answer: B
Rationale: All the values are abnormal, but the low PaO2 indicates that the patient is at the point on the oxyhemoglobin dissociation curve where a small change in the PaO2 will cause a large drop in the O2 saturation and a decrease in tissue oxygenation. The nurse should intervene immediately to improve the patient's oxygenation.
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.
Which of the following lung structures has the most generations?
- A. Segmental bronchi
- B. Subsegmental bronchi
- C. Bronchioles
- D. Alveoli
Correct Answer: D
Rationale: The lung structure that has the most generations is the alveoli with 28. Segmental bronchi, subsegmental bronchi, and bronchioles have less than 28 generations.