Exam 1 Test Bank
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. - ANSB
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.
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 - ANSD
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.
.
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 - ANSB
,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.
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 - ANSA
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.
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.
c. Review the chest x-ray report for evidence of pneumonia.
d. Auscultate anterior and posterior breath sounds bilaterally. - ANSD
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.
,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. - ANSB
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.
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
d. A series of long-duration, discontinuous, low-pitched sounds during inspiration - ANSC
Fine crackles are likely to be heard in the early phase of heart failure. Fine crackles are
discontinuous, high- pitched sounds of short duration heard on inspiration.
.
.
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. - ANSC
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.
, 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. - ANSC
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.
.
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. - ANSC
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.
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. - ANSD
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. - ANSB
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.
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 - ANSD
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.
.
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 - ANSB
,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.
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 - ANSA
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.
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.
c. Review the chest x-ray report for evidence of pneumonia.
d. Auscultate anterior and posterior breath sounds bilaterally. - ANSD
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.
,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. - ANSB
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.
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
d. A series of long-duration, discontinuous, low-pitched sounds during inspiration - ANSC
Fine crackles are likely to be heard in the early phase of heart failure. Fine crackles are
discontinuous, high- pitched sounds of short duration heard on inspiration.
.
.
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. - ANSC
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.
, 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. - ANSC
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.
.
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. - ANSC
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.
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. - ANSD
