vSim Health Assessment | Christopher Parrish (Respiratory Assessment) with correct answers

Which nursing actions pertain to the objective portion of a respiratory assessment? (Select all that apply) a. Gather equipment, including a light source and a metric ruler d. Be attentive to the patient's verbal and nonverbal responses r/t the need for privacy e. Encourage the patient to ask questions A dark-skinned patient is being assessed after reporting dyspnea. Which documentation best reflects the nurse's understanding of the effects of cyanosis on this specific patient? Bluish, dull skin is noted in the perioral area Explanation: Cyanosis makes white skin appear blue-tinged, especially in the perioral, nail bed, and conjunctival areas. Dark skin appears blue, dull, and lifeless in the same areas. The remaining options identify possible hypoxia with resulting cyanosis but are not unique to a dark-skinned individual. 00:21 01:27 The nurse is assessing a patient for crepitus. Which hand placement technique will the nurse use to perform this assessment effectively? Use fingertips to palpate the anterior and posterior chest During a respiratory assessment, the nurse auscultates what may be an adventitious lung sound. What is the nurse's initial response? Ask the patient to cough Explanation: If the nurse hears an abnormal sound during auscultation, always have the patient cough, then listen again and note any change. Coughing may clear the lungs. There is no need to assess the opposite side to compare sounds. Reassessment of the area should take place after having the patient cough. Having the patient take a deep breath is not as likely to clear the lungs. The nurse is preparing to continuously monitor a patient's arterial oxygen saturation levels using a pulse oximetry ear probe. Which conditions will the nurse monitor for their effects on the accuracy of the reading? (Select all that apply) a. Excessive movement by the patient b. Proper contact between the probe and the patient's ear lobe c. A drop in systolic blood pressure Explanation: Hypotension, excessive movement, hypothermia, and improper positioning of the device can produce inaccurate readings. A patient diagnosed with cystic fibrosis suggests asking the provider to order chest physiotherapy because "it has always helped me get up the secretions in the past". Which action will the nurse take when the patient's medical history reports a recent myocardial infarction (MI)? Explain that chest physiotherapy is contraindicated by the patient's recent MI. The nurse has concluded discharge education for a patient diagnosed with cystic fibrosis. Which patient statement(s) indicate that the education has been effective? (Select all that apply) a. We have the furnace filters changed regularly to help manage dust. b. Staying hydrated is important so I drink water throughout the day. c. Everyone in the family knows how to help my chest percussion treatments. e. I know it's very important to avoid being around tobacco smoke. The nurse's patient, Christopher Parrish, is being monitored for the effects of cystic fibrosis on his respiratory function r/t the nursing diagnosis of Ineffective Airway Clearance. The following data have been recorded in his medical record by the nursing staff. Which data directly reflect his impaired ability to get oxygen into his lung? (Select all that apply) b. Pulse oximetry: 95% on 2 L/min. nasal cannula c. Incentive spirometry every hour while awake has been tolerated well d. Arterial blood gas (ABG): ph 7.3, PaO2 50 mmHg, PaCo2 50 mmHg The nurse's patient, Christopher Parrish, is being prepared for discharge. Which responses by the patient or his mother indicate an understanding of how chest physiotherapy should be performed? (Select all that apply) b. We never do chest physiotherapy right before or within 2 hours of Chris eating. c. Inhaling deeply through my nose and then exhaling in puffs really helps me cough up the sputum. d. I use my nebulizer before the percussion to prevent bronchospasms. The nurse is assessing the lung sounds of a patient diagnosed with cystic fibrosis who is experiencing dyspnea. Which finding would the nurse associate with the pathophysiology associated with this diagnosis? Diminished breath sounds in lung bases bilaterally. A patient is experiencing hypoxia r/t an ineffective airway. Which assessment findings support the presence of hypoxia? (Select all that apply) c. Nasal flaring d. Cyanotic nail beds Which finding by the nurse best supports the presence of obstructive secretions in the patient's lungs? Crackles occurring early in the inspiration phase