Med-Surg Chapter 26 Lewis Respiratory |\ |\ |\ |\ |\
System NCLEX questions with answers |\ |\ |\ |\
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. - CORRECT ANSWERS ✔✔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.
|\ |\ |\ |\ |\ |\ |\ |\
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-Fowler's 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 -
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
CORRECT ANSWERS ✔✔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 |\ |\
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)
|\ |\ |\ |\
d. Decreased venous O2 pressure - CORRECT ANSWERS ✔✔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.
|\ |\ |\ |\ |\ |\ |\ |\
On auscultation of a patient's 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
|\ |\ |\ |\ |\
System NCLEX questions with answers |\ |\ |\ |\
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. - CORRECT ANSWERS ✔✔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.
|\ |\ |\ |\ |\ |\ |\ |\
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-Fowler's 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 -
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
CORRECT ANSWERS ✔✔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 |\ |\
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)
|\ |\ |\ |\
d. Decreased venous O2 pressure - CORRECT ANSWERS ✔✔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.
|\ |\ |\ |\ |\ |\ |\ |\
On auscultation of a patient's 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
|\ |\ |\ |\ |\
