ATI LPN
Lewis's Medical Surgical Nursing in Canada, 5th Edition
Chapter 28 Questions
Question 1 of 5
The nurse is admitting a patient with acute shortness of breath. Which of the following actions should the nurse take during the initial assessment of the patient?
Correct Answer: D
Rationale: 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. A focused physical assessment should be done rapidly to help determine the cause of the distress and suggest treatment. Although family members may know about the patient's history of medical problems, the patient is the best informant for these data.
Question 2 of 5
The nurse is preparing a patient with a right-sided pleural effusion for a thoracentesis. Which of the following positions should the nurse position the patient?
Correct Answer: D
Rationale: 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.
Question 3 of 5
The nurse is caring for a patient with a metabolic acidosis of unknown origin. Which of the following findings should the nurse expect based on this diagnosis?
Correct Answer: B
Rationale: Kussmaul's (deep and rapid) respirations are a compensatory mechanism for metabolic acidosis. Intercostal retractions, a low oxygen saturation rate, and a decrease in PO2 would not be caused by acidosis.
Question 4 of 5
The nurse is auscultaining a patient's lungs and hears short, high-pitched sounds during exhalation in the lower 1/3 of both lungs. Which of the following information should the nurse document?
Correct Answer: B
Rationale: Wheezes are high-pitched sounds. In this case they are heard during the expiratory phase of the respiratory cycle. Abnormal breath sounds are either bronchial or bronchovescular sounds heard in the peripheral lung fields. Crackles are low-pitched, 'bubbling' sounds. Pleural friction rubs are grating sounds that are usually heard during both inspiration and expiration.
Question 5 of 5
The nurse is palpating the posterior chest of a patient while the patient says '99' and notes that no vibration is felt. Which of the following information should the nurse document?
Correct Answer: C
Rationale:
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.' Different techniques are used to assess for dullness to percussion, decreased breath sounds, and diminished expansion.