1.            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.

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.

2.            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

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.

3.            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

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.

4.            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

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.

5.            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.

ANS: D

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.