Chapter 26 Nursing Assessment Respiratory System

3521 Words Feb 14th, 2015 15 Pages
Chapter 26: Nursing Assessment: Respiratory System
Test Bank
MULTIPLE CHOICE
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
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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. DIF: Cognitive Level: Apply (application)
REF:
486
TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity
6. A patient with a chronic cough has a bronchoscopy. After the procedure, which intervention

by the nurse is most appropriate?
a. Elevate the head of the bed to 80 to 90 degrees.
b. Keep the patient NPO until the gag reflex returns.
c. Place on bed rest for at least 4 hours after bronchoscopy.

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d. 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
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