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Med-Surg Test #1 (Respiratory) Exam/177 Questions with Complete answers
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- Med-Surg Test #1 Exam/177 Questions
Med-Surg Test #1 (Respiratory) Exam/177 Questions with Complete answers
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Med-Surg Test #1 (Respiratory)Exam/177 Questions with Complete
answers
A nurse is auscultating the lung sounds of a client who came to the clinic for
a physical exam. There is not any history of lung disease. What should the
nurse expect to hear?
a. adventitious breath sounds
b. bronchial breath sounds
c. bronchovesicular breath sounds
d. vesicular breath sounds - -answer: c
rationale: the nurse auscultates breath sounds from side to side, moving
from the upper to the lower chest. They listen anteriorly, laterally, and
posteriorly. Normal breath sounds include bronchovesicular sounds.
-A client comes to the doctor's office describing shortness of breath and
strange breath sounds when inhaling deeply. Upon auscultation of the lung
fields, sibilant wheezes are noted. Which of the following statements by the
nurse most correct?
a. "Wheezes result from air passing through narrowed passages."
b. "Wheezes result from air escaping through a pneumothorax."
c. "Wheezes result from air collecting in the pleural cavity."
d. "Wheezes result from air between visceral and parietal pleurae." - -
answer: a
ratioanle: wheezes may be sibilant (hissing/whistling) or sonorous (full and
deep). Sibilant wheezes (formerly called wheezes) are continuous musical
sounds that can be heard during inspiration and expiration; and result from
air passing through narrowed or partially obstructed air passages and are
heard in clients with increased secretions.
-A nurse needs to obtain a sputum specimen from an adult client. Which
nursing action will best facilitate obtaining the specimen?
a. ask the client to spit into the collection container
b. have the client take deep breaths
c. restrict the client's fluids
d. wait until after the client has eaten to get the specimen. - -answer: b
rationale: collecting a sputum specimen have the client rinse their mouth
with tap water; instruct the client to take several deep breaths, cough
forcefully, and expectorate into the container.
, -The nurse is giving instructions to a client having pulmonary angiography.
Which of the following statements is the best evidence that the client
understands the nurse's instructions about what will take place during the
diagnostic procedure? Select all that apply.
a. "I may feel some pressure at the site."
b. "I may have bleeding at the site following the procedure."
c. "I will not be allowed to cough after the procedure."
d. "I will sense a warm, flushed feeling and an urge to cough when the dye is
injected." - -answer: a,d
rationale: during pulmonary angiograpy, the nurse obtains data about the
client's level of anxiety and knowledge of the procedure. The nurse provides
explanations and reinforces the client's understanding. The client will
experience a feeling of pressure on catheter insertion. When the contrast
medium is infused, the client will sense a warm, flushed feeling and an urge
to cough.
-When caring for a client having a lung scan, which of the following nursing
interventions is most important during the procedure?
a. reassure the client about the amount of radiation from the procedure.
b. coach the client to hold his or her breath at times during the procedure
c.administer sedative or narcotic as per orders before the procedure
d. aid the client to rest arms and head on a pillow during the procedure. - -
answer: a
rationale: the client must receive adequate explanations before the
procedure to reduce anxiety. The nurse must reassure the client that the
amount of radiation from this procedure is less than that used during a chest
x-ray.
-Movement of air into and out of the lungs sufficient to maintain normal
arterial oxygen and carbon dioxide tensions is termed what?
a. perfusion
b. ventilation
c. diffusion
d. inspiration - -answer: b
rationale: ventilation is the actual movement of air in and out of the
respiratory tract. This process requires a patent airway and intact and
functioning respiratory muscles.
-While conducting the physical examination during assessment of the
respiratory system, which of the following would describe lung sounds
produced by air movement through the trachea and are loud with long
expiration?
a. bronchovesicular sounds
, b. bronchial sounds
c. sonorous wheezes
d. vesicular sounds - -answer: b
rationale: normal bronchial lung sounds are auscultated over the trachea and
are loud with long expiration.
-The physician orders arterial blood gases (ABGs) to determine various
factors related to blood oxygenation on a patient who presents in respiratory
distress. What site can ABGs be obtained from?
a. a puncture in the raidal artery
b. the trachea and bronchi
c. a swab from the nasopharynx
d. an intravenous catheter in the arm vein - -answer: a
rationale: ABGs determine the blood's ph; oxygen-carrying capacity; and
levels of: oxygen, carbon dioxide, and bicarbonate ion. Blood gas samples
are obtained through an arterial puncture at the radial, brachial, or femoral
artery.
-Of the following instructions, which is most important for the nurse to teach
the client to help loosen secretions and increase comfort during medical
treatment for sinusitis?
a. blow the nose frequently
b. elevate the head of the bed by 45 degrees
c. engage in normal activity
d. increase fluid intake - -answer: d
rationale: the nurse needs to inform the client receiving medical treatment
for sinusitis that use of mouthwashes and humidification as well as increased
fluid intake may loosen secretions and increase comfort; the nurse should
also instruct the client to take nasal decongestants and antihistamines as
ordered.
-The nurse is providing postoperative care for a client who has undergone
tonsillectomy. In which position will the nurse place the head of the bed
when the client is fully awake?
a. flat with the head elevated on a pillow
b. slightly raised at a 15 degree angle
c. raised at a 45 degree angle
d. raised at a 90 degree sitting position - -answer: c
rationale: elevate head of bed to semi-fowler's position (45 degrees) when
the client is fully awake. This position decreases surgical edema and
increases lung expansion.
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