MedSurg NCLEX Exam 3 - Questions for test respiratory

MedSurg NCLEX Exam 3 - Questions for test respiratory 5.0 (7 reviews) Students also studied Terms in this set (18) Science MedicineNursing Save Respiratory Exam Med-Surg 27 terms meagan_nance9 Preview Respiratory Disorders NCLEX questi...43 terms SetfiretoitPreview Respiratory NCLEX Questions 131 terms rwillia2Preview Fluid an 33 terms Ale 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?

• Ask the patient to lie down to complete a full physical

assessment.

• Briefly ask specific questions about this episode of

respiratory distress.

• Complete the admission database to check for

allergies before treatment.

• Delay the physical assessment to first complete

pulmonary function tests

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?

• Supine with the head of the bed elevated 30 degrees
• In a high-Fowler's position with the left arm extended
• On the right side with the left arm extended above the

head

• Sitting upright with the arms supported on an over bed

table

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?

• Intercostal retractions
• Kussmaul respirations
• Low oxygen saturation (SpO2)
• Decreased venous O2 pressure

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?

• Inspiratory crackles at the bases
• Expiratory wheezes in both lungs
• Abnormal lung sounds in the apices of both lungs
• Pleural friction rub in the right and left lower lobes

ANS: A

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.A patient with a chronic cough has a bronchoscopy. After the procedure, which intervention by the nurse is most appropriate?

• Elevate the head of the bed to 80 to 90 degrees.
• Keep the patient NPO until the gag reflex returns.
• Place on bed rest for at least 4 hours after

bronchoscopy.

• Notify the health care provider about blood-tinged

mucus.

ANS: B

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-Fowler's position.The nurse completes a shift assessment on a patient admitted in the early phase of heart failure. When auscultating the patient's lungs, which finding would the nurse most likely hear?

• Continuous rumbling, snoring, or rattling sounds mainly

on expiration

• Continuous high-pitched musical sounds on inspiration

and expiration

• Discontinuous, high-pitched sounds of short duration

heard on inspiration

• A series of long-duration, discontinuous, low-pitched

sounds during inspiration

ANS: C

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. Rhonchi are continuous rumbling, snoring, or rattling sounds mainly on expiration. Course crackles are a series of long-duration, discontinuous, low- pitched sounds during inspiration. Wheezes are continuous high-pitched musical sounds on inspiration and expiration.The nurse observes a student who is listening to a patient's lungs who is having no problems with breathing.Which action by the student indicates a need to review respiratory assessment skills?

• The student starts at the apices of the lungs and moves

to the bases.

• The student compares breath sounds from side to side

avoiding bony areas.

• The student places the stethoscope over the posterior

chest and listens during inspiration.

• The student instructs the patient to breathe slowly and

a little more deeply than normal through the mouth.

ANS: C

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 is admitted to the emergency department complaining of sudden onset shortness of breath and is diagnosed with a possible pulmonary embolus. How should the nurse prepare the patient for diagnostic testing to confirm the diagnosis?

• Start an IV so contrast media may be given.
• Ensure that the patient has been NPO for at least 6

hours.

• Inform radiology that radioactive glucose preparation

is needed.

• Instruct the patient to undress to the waist and remove

any metal objects.

ANS: A

Spiral computed tomography (CT) scans are the most commonly used test to diagnose pulmonary emboli, and contrast media may be given IV. A chest x-ray may be ordered but will not be diagnostic for a pulmonary embolus. Preparation for a chest x-ray includes undressing and removing any metal. Bronchoscopy is used to detect changes in the bronchial tree, not to assess for vascular changes, and the patient should be NPO 6 to 12 hours before the procedure. Positron emission tomography (PET) scans are most useful in determining the presence of malignancy, and a radioactive glucose preparation is used.A patient with acute dyspnea is scheduled for a spiral computed tomography (CT) scan. Which information obtained by the nurse is a priority to communicate to the health care provider before the CT?

• Allergy to shellfish
• Apical pulse of 104
• Respiratory rate of 30
• Oxygen saturation of 90%

ANS: A

Because iodine-based contrast media is used during a spiral CT, the patient may need to have the CT scan without contrast or be premedicated before injection of the contrast media. The increased pulse, low oxygen saturation, and tachypnea all indicate a need for further assessment or intervention but do not indicate a need to modify the CT procedure.The nurse analyzes the results of a patient's arterial blood gases (ABGs). Which finding would require immediate action?

• The bicarbonate level (HCO3-) is 31 mEq/L.
• The arterial oxygen saturation (SaO2) is 92%.
• The partial pressure of CO2 in arterial blood (PaCO2) is

31 mm Hg.

• The partial pressure of oxygen in arterial blood (PaO2)

is 59 mm Hg.

ANS: D

All the values are abnormal, but the low PaO2 indicates that the patient is at the point on the oxyhemoglobin dissociation curve where a small change in the PaO2 will cause a large drop in the O2 saturation and a decrease in tissue oxygenation.The nurse should intervene immediately to improve the patient's oxygenation.A patient in metabolic alkalosis is admitted to the emergency department, and pulse oximetry (SpO2) indicates that the O2 saturation is 94%. Which action should the nurse take next?

• Administer bicarbonate.
• Complete a head-to-toe assessment.
• Place the patient on high-flow oxygen.
• Obtain repeat arterial blood gases (ABGs).

ANS: C

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. Bicarbonate would worsen the patient's condition. A head-to-toe assessment and repeat ABGs may be implemented. However, the priority intervention is to give high-flow oxygen.After the nurse has received change-of-shift report, which patient should the nurse assess first?

• A patient with pneumonia who has crackles in the right

lung base

• A patient with possible lung cancer who has just

returned after bronchoscopy

• A patient with hemoptysis and a 16-mm induration with

tuberculin skin testing

• A patient with chronic obstructive pulmonary disease

(COPD) and pulmonary function testing (PFT) that indicates low forced vital capacity

ANS: B

Because the cough and gag are decreased after bronchoscopy, this patient should be assessed for airway patency. The other patients do not have clinical manifestations or procedures that require immediate assessment by the nurse.

The laboratory has just called with the arterial blood gas (ABG) results on four patients. Which result is most important for the nurse to report immediately to the health care provider?

• pH 7.34, PaO2 82 mm Hg, PaCO2 40 mm Hg, and O2

sat 97%

• pH 7.35, PaO2 85 mm Hg, PaCO2 45 mm Hg, and O2

sat 95%

• pH 7.46, PaO2 90 mm Hg, PaCO2 32 mm Hg, and O2

sat 98%

• pH 7.31, PaO2 91 mm Hg, PaCO2 50 mm Hg, and O2 sat

96%

ANS: D

These ABGs indicate uncompensated respiratory acidosis and should be reported to the health care provider. The other values are normal or close to normal.A patient is scheduled for a computed tomography (CT) of the chest with contrast media. Which assessment findings should the nurse immediately report to the health care provider (select all that apply)?

• Patient is claustrophobic.
• Patient is allergic to shellfish.
• Patient recently used a bronchodilator inhaler.
• Patient is not able to remove a wedding band.
• Blood urea nitrogen (BUN) and serum creatinine levels

are elevated.

ANS: B, E

Because the contrast media is iodine-based and may cause dehydration and decreased renal blood flow, asking about iodine allergies (such as allergy to shellfish) and monitoring renal function before the CT scan are necessary. The other actions are not contraindications for CT of the chest, although they may be for other diagnostic tests, such as magnetic resonance imaging (MRI) or pulmonary function testing (PFT).A nurse obtains a health history from a patient who has a 35 pack-year smoking history. The patient complains of hoarseness and tightness in the throat and difficulty swallowing. Which question is most important for the nurse to ask?

• "How much alcohol do you drink in an average week?"
• "Do you have a family history of head or neck cancer?"
• "Have you had frequent streptococcal throat

infections?"

• "Do you use antihistamines for upper airway

congestion?"

ANS: A

Prolonged alcohol use and smoking are associated with the development of laryngeal cancer, which the patient's symptoms and history suggest. Family history is not a risk factor for head or neck cancer. Frequent antihistamine use would be asked about if the nurse suspected allergic rhinitis, but the patient's symptoms are not suggestive of this diagnosis. Streptococcal throat infections also may cause these clinical manifestations, but patients with this type of infection will also have pain and a fever.The nurse is reviewing laboratory results and notes an aPTT level of 28 seconds. The nurse should notify the health care provider in anticipation of adjusting which medication?

• Aspirin
• Heparin
• Warfarin
• Erythropoietin

ANS: B

Activated partial thromboplastin time (aPTT) assesses intrinsic coagulation by measuring factors I, II, V, VIII, IX, X, XI, XII. aPTT is increased (prolonged) in heparin administration.aPTT is used to monitor whether heparin is at a therapeutic level (needs to be greater than the normal range of 25 to 35 sec). Prothrombin time (PT) and international normalized ratio (INR) are most commonly used to test for therapeutic levels of warfarin (Coumadin). Aspirin affects platelet function.Erythropoietin is used to stimulate red blood cell production.