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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
b. Briefly ask specific questions about this episode of respiratory distress.
respiratory distress.
c. Complete the admission database to check for allergies
before treatment.
d. Delay the physical assessment to first complete pul-
monary function tests.
The nurse prepares a patient with a left-sided pleural ef-
fusion for a thoracentesis. How should the nurse position
the patient?
a. High-Fowler's position with the left arm extended d. Sitting upright with the arms supported on an over bed
b. Supine with the head of the bed elevated 30 degrees table
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
A diabetic patient's 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)
b. Kussmaul respirations
d. Decreased venous O2 pressure
On auscultation of a patient's lungs, the nurse hears
low-pitched, bubbling sounds during inhalation in the
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lower third of both lungs. How should the nurse docu-
ment this finding?
a. Inspiratory crackles at the bases 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
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.
d. Auscultate anterior and posterior breath sounds bilat-
b. Encourage the patient to turn, cough, and deep
erally.
breathe.
c. Review the chest x-ray report for evidence of pneumo-
nia.
d. Auscultate anterior and posterior breath sounds bilat-
erally.
A patient with a chronic cough is scheduled to have a
bronchoscopy with biopsy. Which intervention will the
nurse implement directly after the procedure?
c. Keep the patient NPO until the gag reflex returns.
a. Encourage the patient to drink clear liquids.
b. Place the patient on bed rest for at least 4 hours.
c. Keep the patient NPO until the gag reflex returns.
d. Maintain the head of the bed elevated 90 degrees.
The nurse completes a shift assessment on a patient ad-
mitted in the early phase of heart failure. When auscul-
tating the patient's lungs, which finding would the nurse
most likely hear?
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a. Continuous rumbling, snoring, or rattling sounds main-
ly on expiration
b. Continuous high-pitched musical sounds on inspiration
and expiration c. Discontinuous, high-pitched sounds of short duration
c. Discontinuous, high-pitched sounds of short duration during inspiration
during inspiration
d. A series of long-duration, discontinuous, low-pitched
sounds during inspiration
The nurse observes that a patient with respiratory disease
experiences a decrease in SpO2 from 93% to 88% while
the patient is ambulating. What is the priority action of the
nurse?
b. Administer PRN supplemental O2.
a. Notify the health care provider.
b. Administer PRN supplemental O2.
c. Document the response to exercise.
d. Encourage the patient to pace activity.
The nurse teaches a patient about pulmonary spirometry
testing. Which statement, if made by the patient, indicates
teaching was ettective?
a. "I should use my inhaler right before the test."
c. "I will inhale deeply and blow out hard during the test."
b. "I won't eat or drink anything 8 hours before the test."
c. "I will inhale deeply and blow out hard during the test."
d. "My blood pressure and pulse will be checked every 15
minutes."
The nurse observes a student who is listening to a pa-
tient's lungs. Which action by the student indicates a need
to review respiratory assessment skills?
a. The student compares breath sounds from side to side
at each level.
b. The student listens during the inspiratory phase, then
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moves the stethoscope.
c. The student starts at the apices of the lungs, moving
The student listens during the inspiratory phase, then
down toward the lung bases.
moves the stethoscope.
d. The student instructs the patient to breathe slowly and
deeply through the mouth.
A patient who has a history of chronic obstructive pul-
monary 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 ettective in improving compliance
with discharge teaching?
c. Arrange for the patient's caregiver to be present during
a. Have the patient repeat the instructions immediately
the teaching.
after teaching.
b. Accomplish the patient teaching just before the sched-
uled discharge.
c. Arrange for the patient's caregiver to be present during
the teaching.
d. Start giving the patient discharge teaching during the
admission process.
A patient admitted to the emergency department com-
plaining of sudden onset shortness of breath is diag-
nosed with a possible pulmonary embolus. How should
the nurse prepare the patient for diagnostic testing to
confirm the diagnosis?
a. Ensure that the patient has been NPO. b. Start an IV so contrast media may be given.
b. Start an IV so contrast media may be given.
c. Inform radiology that radioactive glucose preparation is
needed.
d. Instruct the patient to expect to inspire deeply and
exhale forcefully.