Chapter 25 Assessment of Respiratory System PDF

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TestBank-Medical-SurgicalNursing:AssessmentandManagementofClinicalProblems10e

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Chapter25:AssessmentofRespiratorySystem TestBank MULTIPLECHOICE 1.Apatientwithacuteshortnessofbreathisadmittedtothehospital.Whichactionshouldthenursetake duringtheinitialassessmentofthepatient? a.

Askthepatienttoliedowntocompleteafullphysicalassessment.

b.

Brieflyaskspecificquestionsaboutthisepisodeofrespiratorydistress.

c.

Completetheadmissiondatabasetocheckforallergiesbeforetreatment.

d.

Delaythephysicalassessmenttofirstcompletepulmonaryfunctiontests.

ANS:B Whenapatienthassevererespiratorydistress,onlyinformationpertinenttothecurrentepisodeisobtained, andamorethoroughassessmentisdeferreduntillater.Obtainingacomprehensivehealthhistoryorfull physicalexaminationisunnecessaryuntiltheacutedistresshasresolved.Briefquestioningandafocused physicalassessmentshouldbedonerapidlytohelpdeterminethecauseofthedistressandsuggest treatment.Checkingforallergiesisimportant,butitisnotappropriatetocompletetheentireadmission databaseatthistime.Theinitialrespiratoryassessmentmustbecompletedbeforeanydiagnostictestsor interventionscanbeordered. DIF:CognitiveLevel:Apply(application)REF:460 TOP:NursingProcess:AssessmentMSC:NCLEX:PhysiologicalIntegrity 2.Thenursepreparesapatientwithaleft-sidedpleuraleffusionforathoracentesis.Howshouldthenurse positionthepatient? a.

Supinewiththeheadofthebedelevated30degrees

b.

Inahigh-Fowlerspositionwiththeleftarmextended

c.

Ontherightsidewiththeleftarmextendedabovethehead

d.

Sittinguprightwiththearmssupportedonanoverbedtable

ANS:D 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. DIF:CognitiveLevel:Apply(application)REF:470 TOP:NursingProcess:ImplementationMSC:NCLEX:PhysiologicalIntegrity

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3.Adiabeticpatientsarterialbloodgas(ABG)resultsarepH7.28;PaCO234mmHg;PaO285mmHg; HCO318mEq/L.Thenursewouldexpectwhichfinding? a.

Intercostalretractions

b.

Kussmaulrespirations

c.

Lowoxygensaturation(SpO2)

d.

DecreasedvenousO2pressure

ANS:B Kussmaul(deepandrapid)respirationsareacompensatorymechanismformetabolicacidosis.ThelowpHand lowbicarbonateresultindicatemetabolicacidosis.Intercostalretractions,alowoxygensaturationrate,anda decreaseinvenousO2pressurewouldnotbecausedbyacidosis. DIF:CognitiveLevel:Apply(application)REF:457 TOP:NursingProcess:AssessmentMSC:NCLEX:PhysiologicalIntegrity 4.Onauscultationofapatientslungs,thenursehearslow-pitched,bubblingsoundsduringinhalationinthe lowerthirdofbothlungs.Howshouldthenursedocumentthisfinding? a.

Inspiratorycracklesatthebases

b.

Expiratorywheezesinbothlungs

c.

Abnormallungsoundsintheapicesofbothlungs

d.

Pleuralfrictionrubintherightandleftlowerlobes

ANS:A Cracklesarelow-pitched,bubblingsoundsusuallyheardoninspiration.Wheezesarehigh-pitchedsounds. Theycanbeheardduringtheexpiratoryorinspiratoryphaseoftherespiratorycycle.Thelowerthirdofboth lungsarethebases,notapices.Pleuralfrictionrubsaregratingsoundsthatareusuallyheardduringboth inspirationandexpiration. DIF:CognitiveLevel:Understand(comprehension)REF:465 TOP:NursingProcess:AssessmentMSC:NCLEX:PhysiologicalIntegrity 5.Thenursepalpatestheposteriorchestwhilethepatientsays99andnotesabsentfremitus.Whichaction shouldthenursetakenext? a.

Palpatetheanteriorchestandobserveforbarrelchest.

b.

Encouragethepatienttoturn,cough,anddeepbreathe.

TestBank-Medical-SurgicalNursing:AssessmentandManagementofClinicalProblems10e

c.

Reviewthechestx-rayreportforevidenceofpneumonia.

d.

Auscultateanteriorandposteriorbreathsoundsbilaterally.

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ANS:D Toassessfortactilefremitus,thenurseshouldusethepalmsofthehandstoassessforvibrationwhenthe patientrepeatsawordorphrasesuchas99.Afternotingabsentfremitus,thenurseshouldthenauscultatethe lungstoassessforthepresenceorabsenceofbreathsounds.Absentfremitusmaybenotedwithpneumothorax oratelectasis.Thevibrationisincreasedinconditionssuchaspneumonia,lungtumors,thickbronchial secretions,andpleuraleffusion.Turning,coughing,anddeepbreathingisanappropriateinterventionfor atelectasis,butthenurseneedstofirstassessbreathsounds.Fremitusisdecreasedifthehandisfartherfrom thelungorthelungishyperinflated(barrelchest).Theanteriorofthechestismoredifficulttopalpatefor fremitusbecauseofthepresenceoflargemusclesandbreasttissue. DIF:CognitiveLevel:Apply(application)REF:464 TOP:NursingProcess:AssessmentMSC:NCLEX:PhysiologicalIntegrity 6.Apatientwithachroniccoughhasabronchoscopy.Aftertheprocedure,whichinterventionbythenurseis mostappropriate? a.

Elevatetheheadofthebedto80to90degrees.

b.

KeepthepatientNPOuntilthegagreflexreturns.

c.

Placeonbedrestforatleast4hoursafterbronchoscopy.

d.

Notifythehealthcareprovideraboutblood-tingedmucus.

ANS:B Riskforaspirationandmaintaininganopenairwayisthepriority.Becausealocalanestheticisusedto suppressthegag/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-Fowlersposition. DIF:CognitiveLevel:Apply(application)REF:470 TOP:NursingProcess:PlanningMSC:NCLEX:PhysiologicalIntegrity 7.Thenursecompletesashiftassessmentonapatientadmittedintheearlyphaseofheartfailure.When auscultatingthepatientslungs,whichfindingwouldthenursemostlikelyhear? a.

Continuousrumbling,snoring,orrattlingsoundsmainlyonexpiration

b.

Continuoushigh-pitchedmusicalsoundsoninspirationandexpiration

c.

Discontinuous,high-pitchedsoundsofshortdurationheardoninspiration

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d.

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Aseriesoflong-duration,discontinuous,low-pitchedsoundsduringinspiration

ANS:C Finecracklesarelikelytobeheardintheearlyphaseofheartfailure.Finecracklesarediscontinuous,highpitchedsoundsofshortdurationheardoninspiration.Rhonchiarecontinuousrumbling,snoring,orrattling soundsmainlyonexpiration.Coursecracklesareaseriesoflong-duration,discontinuous,low-pitchedsounds duringinspiration.Wheezesarecontinuoushigh-pitchedmusicalsoundsoninspirationandexpiration. DIF:CognitiveLevel:Apply(application)REF:467 TOP:NursingProcess:AssessmentMSC:NCLEX:PhysiologicalIntegrity 8.Whilecaringforapatientwithrespiratorydisease,thenurseobservesthatthepatientsSpO2dropsfrom 93%to88%whilethepatientisambulatinginthehallway.Whatisthepriorityactionofthenurse? 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.

ANS:C ThedropinSpO2to85%indicatesthatthepatientishypoxemicandneedssupplementaloxygenwhen exercising.Theotheractionsarealsoimportant,butthefirstactionshouldbetocorrectthehypoxemia. DIF:CognitiveLevel:Apply(application)REF:458 OBJ:SpecialQuestions:PrioritizationTOP:NursingProcess:Implementation MSC:NCLEX:PhysiologicalIntegrity 9.Thenurseteachesapatientaboutpulmonaryfunctiontesting(PFT).Whichstatement,ifmadebythe patient,indicatesteachingwaseffective? a.

Iwillusemyinhalerrightbeforethetest.

b.

Iwonteatordrinkanything8hoursbeforethetest.

c.

IshouldinhaledeeplyandblowoutashardasIcanduringthetest.

d.

Mybloodpressureandpulsewillbecheckedevery15minutesafterthetest.

ANS:C 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administrationofinhaledbronchodilatorsshouldbeavoided6hoursbeforethe procedure.

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DIF:CognitiveLevel:Apply(application)REF:471 TOP:NursingProcess:PlanningMSC:NCLEX:PhysiologicalIntegrity 10.Thenurseobservesastudentwhoislisteningtoapatientslungswhoishavingnoproblemswithbreathing Whichactionbythestudentindicatesaneedtoreviewrespiratoryassessmentskills? a.

Thestudentstartsattheapicesofthelungsandmovestothebases.

b.

Thestudentcomparesbreathsoundsfromsidetosideavoidingbonyareas.

c.

Thestudentplacesthestethoscopeovertheposteriorchestandlistensduringinspiration.

d.

Thestudentinstructsthepatienttobreatheslowlyandalittlemoredeeplythannormalthroughthe mouth.

ANS:C Listeningonlyduringinspirationindicatesthestudentneedsareviewofrespiratoryassessmentskills.Ateach placementofthestethoscope,listentoatleastonecycleofinspirationandexpiration.Duringchest auscultation,instructthepatienttobreatheslowlyandalittledeeperthannormalthroughthemouth. Auscultationshouldproceedfromthelungapicestothebases,comparingoppositeareasofthechest,unless thepatientisinrespiratorydistressorwilltireeasily.Ifso,startatthebases(seeFig.26-7).Placethe stethoscopeoverlungtissue,notoverbonyprominences. DIF:CognitiveLevel:Apply(application)REF:464 TOP:NursingProcess:AssessmentMSC:NCLEX:SafeandEffectiveCareEnvironment 11.Apatientwhohasahistoryofchronicobstructivepulmonarydisease(COPD)washospitalizedfor increasingshortnessofbreathandchronichypoxemia(SaO2levelsof89%to90%).Inplanningfordischarge, whichactionbythenursewillbemosteffectiveinimprovingcompliancewithdischargeteaching? a.

Startgivingthepatientdischargeteachingonthedayofadmission.

b.

Havethepatientrepeattheinstructionsimmediatelyafterteaching.

c.

Accomplishthepatientteachingjustbeforethescheduleddischarge.

d.

Arrangeforthepatientscaregivertobepresentduringtheteaching.

ANS:D Hypoxemiainterfereswiththepatientsabilitytolearnandretaininformation,sohavingthepatientscaregiver presentwillincreasethelikelihoodthatdischargeinstructionswillbefollowed.Havingthepatientrepeatthe instructionswillindicatethattheinformationisunderstoodatthetime,butitdoesnotguaranteeretentionof theinformation.Becausethepatientislikelytobedistractedjustbeforedischarge,givingdischarge instructionsjustbeforedischargeisnotideal.Thepatientislikelytobeanxiousandevenmorehypoxemic thanusualonthedayofadmission,soteachingaboutdischargeshouldbepostponed. DIF:CognitiveLevel:Apply(application)REF:462

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TOP:NursingProcess:PlanningMSC:NCLEX:PhysiologicalIntegrity 12.Apatientisadmittedtotheemergencydepartmentcomplainingofsuddenonsetshortnessofbreathandis diagnosedwithapossiblepulmonaryembolus.Howshouldthenursepreparethepatientfordiagnostictesting toconfirmthediagnosis? a.

StartanIVsocontrastmediamaybegiven.

b.

EnsurethatthepatienthasbeenNPOforatleast6hours.

c.

Informradiologythatradioactiveglucosepreparationisneeded.

d.

Instructthepatienttoundresstothewaistandremoveanymetalobjects.

ANS:A Spiralcomputedtomography(CT)scansarethemostcommonlyusedtesttodiagnosepulmonaryemboli,and contrastmediamaybegivenIV.Achestx-raymaybeorderedbutwillnotbediagnosticforapulmonary embolus.Preparationforachestx-rayincludesundressingandremovinganymetal.Bronchoscopyisusedto detectchangesinthebronchialtree,nottoassessforvascularchanges,andthepatientshouldbeNPO6to12 hoursbeforetheprocedure.Positronemissiontomography(PET)scansaremostusefulindeterminingthe presenceofmalignancy,andaradioactiveglucosepreparationisused. DIF:CognitiveLevel:Apply(application)REF:470 TOP:NursingProcess:PlanningMSC:NCLEX:PhysiologicalIntegrity 13.Thenurseadmitsapatientwhohasadiagnosisofanacuteasthmaattack.Whichstatementindicatesthat thepatientmayneedteachingregardingmedicationuse? a.

Ihavenothadanyacuteasthmaattacksduringthelastyear.

b.

Ibecameshortofbreathanhourbeforecomingtothehospital.

c.

IvebeentakingTylenol650mgevery6hoursforchest-wallpain.

d.

Ivebeenusingmyalbuterolinhalermorefrequentlyoverthelast4days.

ANS:D Theincreasedneedforarapid-actingbronchodilatorshouldalertthepatientthatanacuteattackmaybe imminentandthatachangeintherapymaybeneeded.Thepatientshouldbetaughttocontactahealthcare providerifthisoccurs.Theotherdatadonotindicateanyneedforadditionalteaching. DIF:CognitiveLevel:Apply(application)REF:460 TOP:NursingProcess:AssessmentMSC:NCLEX:PhysiologicalIntegrity 14.Apatientwithacutedyspneaisscheduledforaspiralcomputedtomography(CT)scan.Whichinformation obtainedbythenurseisaprioritytocommunicatetothehealthcareproviderbeforetheCT?

TestBank-Medical-SurgicalNursing:AssessmentandManagementofClinicalProblems10e

a.

Allergytoshellfish

b.

Apicalpulseof104

c.

Respiratoryrateof30

d.

Oxygensaturationof90%

267

ANS:A Becauseiodine-basedcontrastmediaisusedduringaspiralCT,thepatientmayneedtohavetheCTscan withoutcontrastorbepremedicatedbeforeinjectionofthecontrastmedia.Theincreasedpulse,lowoxygen saturation,andtachypneaallindicateaneedforfurtherassessmentorinterventionbutdonotindicateaneedto modifytheCTprocedure. DIF:CognitiveLevel:Apply(application)REF:470 OBJ:SpecialQuestions:PrioritizationTOP:NursingProcess:Implementation MSC:NCLEX:PhysiologicalIntegrity 15.Thenurseanalyzestheresultsofapatientsarterialbloodgases(ABGs).Whichfindingwouldrequire immediateaction? a.

Thebicarbonatelevel(HCO3)is31mEq/L.

b.

Thearterialoxygensaturation(SaO2)is92%.

c.

ThepartialpressureofCO2inarterialblood(PaCO2)is31mmHg.

d.

Thepartialpressureofoxygeninarterialblood(PaO2)is59mmHg.

ANS:D 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patientsoxygenation. DIF:CognitiveLevel:Apply(application)REF:eTable25-1 OBJ:SpecialQuestions:PrioritizationTOP:NursingProcess:Assessment MSC:NCLEX:PhysiologicalIntegrity 16.Whenassessingtherespiratorysystemofanolderpatient,whichfindingindicatesthatthenurseshould takeimmediateaction? a.

Weakcougheffort

b.

Barrel-shapedchest

TestBank-Medical-SurgicalNursing:AssessmentandManagementofClinicalProblems10e

c.

Drymucousmembranes

d.

Bilateralcracklesatlungbases

268

ANS:D Cracklesinthelowerhalfofthelungsindicatethatthepatientmayhaveanacuteproblemsuchasheart failure.Thenurseshouldimmediatelyaccomplishfurtherassessments,suchasoxygensaturation,andnotify thehealthcareprovider.Abarrel-shapedchest,hyperresonancetopercussion,andaweakcougheffortare associatedwithaging.Furtherevaluationmaybeneeded,butimmediateactionisnotindicated.Anolder patienthasalessforcefulcoughandfewerandlessfunctionalcilia.Mucousmembranestendtobedrier. DIF:CognitiveLevel:Apply(application)REF:467 OBJ:SpecialQuestions:PrioritizationTOP:NursingProcess:Assessment MSC:NCLEX:PhysiologicalIntegrity 17.Apatientinmetabolicalkalosisisadmittedtotheemergencydepartment,andpulseoximetry(SpO2) indicatesthattheO2saturationis94%.Whichactionshouldthenursetakenext? a.

Administerbicarbonate.

b.

Completeahead-to-toeassessment.

c.

Placethepatientonhigh-flowoxygen.

d.

Obtainrepeatarterialbloodgases(ABGs).

ANS:C AlthoughtheO2saturationisadequate,theleftshiftintheoxyhemoglobindissociationcurvewilldecreasethe amountofoxygendeliveredtotissues,sohighoxygenconcentrationsshouldbegiven.Bicarbonatewould worsenthepatientscondition.Ahead-to-toeassessmentandrepeatABGsmaybeimplemented.However,the priorityinterventionistogivehigh-flowoxygen. DIF:CognitiveLevel:Apply(application)REF:eTable25-1 OBJ:SpecialQuestions:PrioritizationTOP:NursingProcess:Implementation MSC:NCLEX:PhysiologicalIntegrity 18.Afterthenursehasreceivedchange-of-shiftreport,whichpatientshouldthenurseassessfirst? a.

Apatientwithpneumoniawhohascracklesintherightlungbase

b.

Apatientwithpossiblelungcancerwhohasjustreturnedafterbronchoscopy

c.

Apatientwithhemoptysisanda16-mmindurationwithtuberculinskintesting

TestBank-Medical-SurgicalNursing:AssessmentandManagementofClinicalProblems10e

d.

269

Apatientwithchronicobstructivepulmonarydisease(COPD)andpulmonaryfunctiontesting (PFT)thatindicateslowforcedvitalcapacity

ANS:B Becausethecoughandgagaredecreasedafterbronchoscopy,thispatientshouldbeassessedforairway patency.Theotherpatientsdonothaveclinicalmanifestationsorproceduresthatrequireimmediate assessmentb...