ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 19 : Introduction to the Respiratory System Questions
Question 1 of 5
A nurse is performing a physical assessment on a client who has a history of a respiratory infection. Which documentation, completed by the nurse, indicates improvement in an area of the lung affected by the infection?
Correct Answer: A
Rationale:
To determine if the client's respiratory infection has resolved, the nurse should assess the client's normal respiratory status. Lungs will return to clear breath sounds. Palpable vibrations will be felt ,as they may be normal if there is no infection in the lungs. A client with consolidation of a lobe of the lung from pneumonia has increased tactile fremitus over that lobe. A decreased fremitus would indicate resolution of infection. Bronchial sounds will be noted over the upper lung fields. An increased fremitus is noted as the client speaks '99.' Dull percussed sounds indicate an area of consolidation or infection.
Question 2 of 5
Including clients with a history of respiratory issues, for which diagnostic stud(ies) would the nurse screen the client for an allergy to contrast medium prior to testing?
Correct Answer: A,C
Rationale: The nurse must be well educated in screening clients before diagnostic procedures, which include contrast medium for an allergy to iodine. A lung scan and pulmonary angiography both require contrast medium. A chest x-ray, bronchoscopy, sputum culture test, and pulmonary functions test do not require contrast medium.
Question 3 of 5
The nurse is caring for a client who is in respiratory distress. The physician orders arterial blood gases (ABGs) to determine various factors related to blood oxygenation. What site can ABGs be obtained from?
Correct Answer: A
Rationale: ABGs determine the blood's pH, oxygen-carrying capacity, levels of oxygen, CO2, and bicarbonate ion. Blood gas samples are obtained through an arterial puncture at the radial, brachial, or femoral artery. A client also may have an indwelling arterial catheter from which arterial samples are obtained. Blood gas samples are not obtained from the pleural surfaces or trachea and bronchi.
Question 4 of 5
The nurse is in the radiology unit of the hospital. The nurse is caring for a client who is scheduled for a lung scan. The nurse knows that lung scans need the use of radioisotopes and a scanning machine. Before the perfusion scan, what must the client be assessed for?
Correct Answer: B
Rationale: During lung scans, a radioactive contrast medium is administered intravenously for the perfusion scan. Before the perfusion scan, nurses must assess the client to check for allergies to iodine. Laryngoscopy determines inflammation. Dysrhythmias and bleeding are possible complications of mediastinoscopy.
Question 5 of 5
What would the instructor tell the students purulent fluid indicates?
Correct Answer: B
Rationale: A small amount of fluid lies between the visceral and parietal pleurae. When excess fluid or air accumulates, the physician aspirates it from the pleural space by inserting a needle into the chest wall. This procedure, called thoracentesis, is performed with local anesthesia. Thoracentesis also may be used to obtain a sample of pleural fluid or a biopsy specimen from the pleural wall for diagnostic purposes such as a culture, sensitivity, or microscopic examination. Purulent fluid is the recommended diagnosis for infection. Serous fluid may be associated with cancer, inflammatory conditions, or heart failure.