Respiratory System Assessment P2 exam |||\\\ |||\\\ |||\\\ |||\\\
with correct answers
|||\\\ |||\\\ |||\\\
1. A patient in severe respiratory distress is admitted to the medical unit at the hospital. During
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
the admission assessment of the patient, what should the nurse do?
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
a. Perform a comprehensive health history with the patient to determine the extent of prior
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
respiratory problems. |||\\\
b. Complete a full physical examination to determine the effect of the respiratory distress on
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
other body functions. |||\\\ |||\\\
c. Delay any physical assessment of the patient, and ask family members about the patient's
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
history of respiratory problems. |||\\\ |||\\\ |||\\\
d. Perform a physical assessment of the respiratory system, and ask specific questions related
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
to this episode of respiratory distress. - correct answersANS: D
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
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. |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
PTS: 1 DIF: Cognitive Level: Application REF: page 617
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
OBJ: 8 TOP: Nursing Process: Assessment MSC: CRNE: CH-1
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
2. A hypothermic patient is admitted to the emergency department, and pulse oximetry (SpO2)
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
indicates that the O2 saturation is 95%. Which action should the nurse take next?
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
a. Complete a head-to-toe assessment.
|||\\\ |||\\\ |||\\\ |||\\\
b. Place the patient on high-flow oxygen.
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
c. Start rewarming the patient.
|||\\\ |||\\\ |||\\\ |||\\\
d. Obtain arterial blood gases. - correct answersANS: B
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
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 until the patient is normothermic.
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
, PTS: 1 DIF: Cognitive Level: Comprehension REF: page 613
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
OBJ: 5 TOP: Nursing Process: Assessment MSC: CRNE: CH-8
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
3. The physician performs a thoracentesis on a patient with a right pleural effusion. In
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
preparing the patient for the procedure, how should the nurse position the patient? |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
a. Supine with the head of the bed elevated 45 degrees
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
b. On his left side with his right arm extended above his head
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
c. Sitting upright with his arms supported on an overbed table
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
d. On his left side in the Trendelenburg's position with both arms extended - correct
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
answersANS: C |||\\\
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.
PTS: 1 DIF: Cognitive Level: Application
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
REF: page 626, Table 28-11 OBJ: 11
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
TOP: Nursing Process: Implementation MSC: CRNE: CH-30
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
4. A patient is admitted with a metabolic acidosis of unknown origin. Based on this diagnosis,
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
the nurse would expect the patient to have which one of the following?
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
a. Kussmaul's respirations
|||\\\ |||\\\
b. Slow, shallow respirations
|||\\\ |||\\\ |||\\\
c. A low oxygen saturation (SpO2)
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\
d. A decrease in PVO2 - correct answersANS: A
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
Kussmaul's (deep and rapid) respirations are a compensatory mechanism for metabolic |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
acidosis.
with correct answers
|||\\\ |||\\\ |||\\\
1. A patient in severe respiratory distress is admitted to the medical unit at the hospital. During
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
the admission assessment of the patient, what should the nurse do?
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
a. Perform a comprehensive health history with the patient to determine the extent of prior
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
respiratory problems. |||\\\
b. Complete a full physical examination to determine the effect of the respiratory distress on
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
other body functions. |||\\\ |||\\\
c. Delay any physical assessment of the patient, and ask family members about the patient's
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
history of respiratory problems. |||\\\ |||\\\ |||\\\
d. Perform a physical assessment of the respiratory system, and ask specific questions related
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
to this episode of respiratory distress. - correct answersANS: D
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
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. |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
PTS: 1 DIF: Cognitive Level: Application REF: page 617
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
OBJ: 8 TOP: Nursing Process: Assessment MSC: CRNE: CH-1
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
2. A hypothermic patient is admitted to the emergency department, and pulse oximetry (SpO2)
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
indicates that the O2 saturation is 95%. Which action should the nurse take next?
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
a. Complete a head-to-toe assessment.
|||\\\ |||\\\ |||\\\ |||\\\
b. Place the patient on high-flow oxygen.
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
c. Start rewarming the patient.
|||\\\ |||\\\ |||\\\ |||\\\
d. Obtain arterial blood gases. - correct answersANS: B
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
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 until the patient is normothermic.
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
, PTS: 1 DIF: Cognitive Level: Comprehension REF: page 613
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
OBJ: 5 TOP: Nursing Process: Assessment MSC: CRNE: CH-8
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
3. The physician performs a thoracentesis on a patient with a right pleural effusion. In
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
preparing the patient for the procedure, how should the nurse position the patient? |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
a. Supine with the head of the bed elevated 45 degrees
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
b. On his left side with his right arm extended above his head
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
c. Sitting upright with his arms supported on an overbed table
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
d. On his left side in the Trendelenburg's position with both arms extended - correct
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
answersANS: C |||\\\
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.
PTS: 1 DIF: Cognitive Level: Application
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
REF: page 626, Table 28-11 OBJ: 11
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
TOP: Nursing Process: Implementation MSC: CRNE: CH-30
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
4. A patient is admitted with a metabolic acidosis of unknown origin. Based on this diagnosis,
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
the nurse would expect the patient to have which one of the following?
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
a. Kussmaul's respirations
|||\\\ |||\\\
b. Slow, shallow respirations
|||\\\ |||\\\ |||\\\
c. A low oxygen saturation (SpO2)
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\
d. A decrease in PVO2 - correct answersANS: A
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
Kussmaul's (deep and rapid) respirations are a compensatory mechanism for metabolic |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
acidosis.
