ATI LPN
Lewis's Medical Surgical Nursing in Canada, 5th Edition
Chapter 28 Questions
Question 1 of 5
The nurse is assessing a patient with chronic obstructive pulmonary disease (COPD) with increasing dyspnea over the last 3 days. Which of the following findings is most important to report to the health care provider?
Correct Answer: A
Rationale: The increase in respiratory rate indicates respiratory distress and a need for rapid interventions such as administration of oxygen or medications. The other findings are common persistent changes occurring in patients with COPD.
Question 2 of 5
The nurse is admitting a patient to the emergency department who has sudden onset shortness of breath and is diagnosed with a possible pulmonary embolus. To confirm the diagnosis, which of the following diagnostic measures should the nurse anticipate?
Correct Answer: D
Rationale: Spiral CT scans are the most commonly used test to diagnose pulmonary emboli. A chest x-ray may be ordered but will not be diagnostic for a pulmonary embolus. Bronchoscopy is used to inspect for changes in the bronchial tree, not to assess for vascular changes. PET scans are most useful in determining the presence of malignancy.
Question 3 of 5
The nurse is assessing the respiratory system of an older-adult patient. Which of the following findings indicate that the nurse should take immediate action?
Correct Answer: C
Rationale: Crackles in the lower half of the lungs indicate that the patient may have an acute problem such as heart failure. The nurse should immediately accomplish further assessments, such as oxygen saturation, and notify the health care provider. A barrel-shaped chest, hyper-resonance to percussion, and a weak cough effort are associated with aging. Further evaluation may be needed, but immediate action is not indicated.
Question 4 of 5
The nurse is caring for a patient with respiratory disease and observes that the patient's SpO2 drops from 92% to 88% while the patient is ambulating in the hallway. Which of the following actions should the nurse take next?
Correct Answer: C
Rationale: The drop in SpO2 to 88% indicates that the patient is hypoxic and needs supplemental oxygen when exercising. The other actions also are appropriate, but the first action should be to correct the hypoxemia.
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.