Exam (elaborations) NURSING MISC (NURSINGMISC) MED SURG EXAM 3.| GRADED A
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NURSING MISC (NURSINGMISC)
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Houston Community College
MED SURG EXAM 3.Chapter 25 Assessment Respiratory System 1. The key anatomic landmark that separates the upper respiratory tract from the lower respiratory tract is the a. carina. b. larynx. c. trachea. d. epiglottis. Rationale: The carina is the anatomic landmark that separates the upper respirato...
the key anatomic landmark that separates the upper respiratory tract from the lower respiratory tract is the
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STUDY GUIDE EXAM 3
Chapter 25 Assessment Respiratory System
1. The key anatomic landmark that separates the upper respiratory tract from the lower respiratory tract is
the
a. carina.
b. larynx.
c. trachea.
d. epiglottis.
Rationale: The carina is the anatomic landmark that separates the upper respiratory tract from the lower
respiratory tract. The larynx, epiglottis, and trachea are all above the carina (part of the upper respiratory
tract).
2. A patient asks, “How does air get into my lungs?” The nurse bases her answer on knowledge that air moves
into the lungs because of
a. positive intrathoracic pressure.
b. contraction of the accessory abdominal muscles.
c. stimulation of the respiratory muscles by the chemoreceptors.
d. a decrease in intrathoracic pressure from an increase in thoracic cavity size.
Rationale: During inspiration, the diaphragm contracts, moves downward, and increases intrathoracic volume.
At the same time, the external intercostal muscles and scalene muscles contract, increasing the lateral and
anteroposterior dimension of the chest. This causes the size of the thoracic cavity to increase and
intrathoracic pressure to decrease. As a result, air is pulled into the lungs.
3. The nurse can best determine adequate arterial oxygenation of the blood by assessing
a. heart rate.
b. hemoglobin level.
c. arterial oxygen partial pressure.
d. arterial carbon dioxide partial pressure.
Rationale: The ability of the lungs to oxygenate arterial blood adequately is determined by examination of the
partial pressure of oxygen in arterial blood (PaO2) and arterial oxygen saturation (SaO2). The heartrate,
hemoglobin level, and mean arterial pressure do not help evaluate oxygenation. PaCO2 evaluates the
ventilation portion.
4. Defense mechanisms that help protect the lung from inhaled particles and microorganisms include the
(select all that apply)
a. cough reflex.
b. mucociliary escalator.
c. alveolar macrophages.
d. reflex bronchoconstriction.
e. alveolar capillary membrane.
Rationale: Respiratory defense mechanisms are efficient in protecting the lungs from inhaled particles,
microorganisms, and toxic gases. These include the cough reflex, mucociliary
5. A student nurse asks the RN what can be measured by arterial blood gas (ABG). The RN tells the student
that the ABG can measure (select all that apply)
a. acid-base balance.
b. oxygenation status.
c. acidity of the blood.
,d. bicarbonate (HCO3–).
e. compliance and resistance.
Rationale: Arterial blood gases (ABGs) are measured to determine oxygenation status, ventilation status, and
acid-base balance. ABG analysis includes measurement of the partial pressure of oxygen in arterial blood
(PaO2), partial pressure of carbon dioxide in arterial blood (PaCO2), acidity (pH), bicarbonate (HCO3–), and
arterial oxygen saturation (SaO2) in arterial blood. Compliance and resistance cannot be determined with
ABGs.
6. To detect early signs or symptoms of inadequate oxygenation, the nurse would examine the patient for
a. dyspnea and hypotension.
b. apprehension and restlessness.
c. cyanosis and cool, clammy skin.
d. increased urine output and diaphoresis.
Rationale: Early symptoms of inadequate oxygenation include unexplained restlessness, apprehension, and
irritability. Dyspnea, hypotension, bradycardia, cyanosis, cool and clammy skin are late signs.
7. During the respiratory assessment of an older adult, the nurse would expect to find (select all that apply)
a. a vigorous reflex cough.
b. increased chest expansion.
c. increased residual volume.
d. decreased lung sounds at base of lungs.
e. increased anteroposterior (AP) chest diameter.
Rationale: The anterior-posterior diameter of the thoracic cage and the residual volume increase in older
adults. An older adult has a less forceful cough. The costal cartilages calcify with aging and interfere with
chest expansion. Decreased breath sounds at the base of lungs is also a common finding in older adults
8. When assessing subjective data related to the respiratory health of a patient with emphysema, the nurse
asks about (select all that apply)
a. date of last chest x-ray.
b. dyspnea during rest or exercise.
c. pulmonary function test results.
d. ability to sleep through the entire night.
e. prescription and over-the-counter medication.
Rationale: Important parts of the subjective respiratory assessment include dyspnea during exercise or at rest,
what medications they are currently taking, and their ability to sleep at night. The date of the last chest x-ray
and pulmonary function test (PFT) results are all objective measures of assessment.
9. When auscultating the chest of an older patient in mild respiratory distress, it is best to
a. begin listening at the apices.
b. begin listening at the lung bases.
c. begin listening on the anterior chest.
d. Ask the patient to breathe through the nose with the mouth closed.
Rationale: Normally, auscultation should proceed from the lung apices tothe bases so that opposite areas of
the chest are compared. For the patient in mild respiratory distress, start at the bases. The patient may not be
able to breathe through the nose with the mouth closed, and, there is no sign that the patient needs
immediate intubation.
10. Which respiratory assessment finding does the nurse interpret as abnormal?
a. Inspiratory chest expansion of 1 inch
b. Symmetric chest expansion and contraction
,c. Resonance (to percussion) over the lung bases
d. Bronchial breath sounds in the lower lung fields
Rationale: Bronchial or bronchovesicular sounds heard in the peripheral lung fields would be abnormal. All
the other assessment findings are considered normal.
11. The nurse is preparing the patient for a diagnostic procedure to remove pleural fluid for analysis. The
nurse would prepare the patient for which test?
a. Thoracentesis
b. Bronchoscopy
c. Pulmonary angiography
d. Sputum culture and sensitivity
Rationale: Thoracentesis is the insertion of a large-bore needle through the chest wall into the pleural space
to obtain specimens for diagnostic evaluation, remove pleural fluid, or instill medication. A paracentesis is
removal of fluid from the abdomen.
25 Assessment: Respiratory System (Study Guide)
2. A 92-year-old female patient is being admitted to the emergency department with severe shortness of
breath. Being aware of the patient’s condition, what approach should the nurse use to assess the patient’s
lungs (select all that apply)?
a. Apex to base
b. Base to apex
c. Lateral sequence
d. Anterior then posterior
e. Posterior then anterior
This patient is older and short of breath. To obtain the most information, auscultate the posterior to avoid
breast tissue and start at the base because of her respiratory difficulty and the chance that she will tire easily.
Important sounds may be missed if the other strategies are used first.
3. What keeps alveoli from collapsing?
a. Carina
b. Surfactant
c. Empyema
d. Thoracic cage
Surfactant is a lipoprotein that lowers the surface tension in the alveoli. It reduces the pressure needed to
inflate the alveoli and decreases the tendency of the alveoli to collapse. The other options do not maintain
inflation of the alveoli. The carina is the point of bifurcation of the trachea into the right and left bronchi.
Empyema is a collection of pus in the thoracic cavity. The thoracic cage is formed by the ribs and protects the
thoracic organs.
4. What accurately describes the alveolar sacs?
a. Line the lung pleura
b. Warm and moisturize inhaled air
c. Terminal structures of the respiratory tract
d. Contain dead air that is not available for gas exchange
Alveolar sacs are terminal structures of the respiratory tract, where gas exchange takes place. The visceral
pleura lines the lungs and forms a closed, double-walled sac with the parietal pleura. Turbinates warm and
moisturize inhaled air. The 150 mL of air is dead space in the trachea and bronchi.
5. What covers the larynx during swallowing?
, a. Trachea
b. Epiglottis
c. Turbinates
d. Parietal pleura
The epiglottis is a small flap closing over the larynx during swallowing. The trachea connects the larynx and
the bronchi. The turbinates in the nose warm and moisturize inhaled air. The parietal pleura is a membrane
that lines the chest cavity.
6. Priority Decision: A 75-year-old patient who is breathing room air has the following arterial blood gas (ABG)
results: pH 7.40, partial pressure of oxygen in arterial blood (PaO2) 74 mm Hg, arterial oxygen saturation
(SaO2) 92%, partial pressure of carbon dioxide in arterial blood (PaCO2) 40 mm Hg. What is the most
appropriate action by the nurse?
a. Document the results in the patient’s record.
b. Repeat the ABGs within an hour to validate the findings.
c. Encourage deep breathing and coughing to open the alveoli.
d. Initiate pulse oximetry for continuous monitoring of the patient’s oxygen status.
Normal findings in arterial blood gases (ABGs) in the older adult include a small decrease in PaO2 and arterial
oxygen saturation (SaO2) but normal pH and PaCO2. No interventions are necessary for these findings. Usual
PaO2 levels are expected in patients 60 years of age or younger.
7. A patient’s ABGs include a PaO2 of 88 mm Hg and a PaCO2 of 38 mm Hg, and mixed venous blood gases
include a partial pressure of oxygen in venous blood (PvO2) of 40 mm Hg and partial pressure of carbon
dioxide in venous blood (PvCO2) of 46 mm Hg. What do these findings indicate?
a. Impaired cardiac output
b. Unstable hemodynamics
c. Inadequate delivery of oxygen to the tissues
d. Normal capillary oxygen–carbon dioxide exchange
Normal venous blood gas values reflect the normal uptake of oxygen from arterial blood and the release of
carbon dioxide from cells into the blood, resulting in a much lower PaO2 and an increased PaCO2. The pH is
also decreased in mixed venous blood gases because of the higher partial pressure of carbon dioxide in
venous blood (PvCO2). Normal mixed venous blood gases also have much lower partial pressure of oxygen in
venous blood (PvO2) and venous oxygen saturation (SvO2) than ABGs. Mixed venous blood gases are used
when patients are hemodynamically unstable to evaluate the amount of oxygen delivered to the tissue and
the amount of oxygen consumed by the tissues.
8. Priority Decision: A pulse oximetry monitor indicates that the patient has a drop in arterial oxygen
saturation by pulse oximetry (SpO2) from 95% to 85% over several hours. What is the first action the nurse
should take?
a. Order stat ABGs to confirm the SpO2 with a SaO2.
b. Start oxygen administration by nasal cannula at 2 L/min.
c. Check the position of the probe on the finger or earlobe.
d. Notify the health care provider of the change in baseline PaO2.
Pulse oximetry is inaccurate if the probe is loose, if there is low perfusion, or when skin color is dark. Before
other measures are taken, the nurse should check the probe site. If the probe is intact at the site and
perfusion is adequate, an ABG analysis will be ordered by the HCP to verify accuracy, and oxygen may be
administered, depending on the patient’s condition and the assessment of respiratory and cardiac status.
9. Pulse oximetry may not be a reliable indicator of oxygen saturation in which patient?
a. Patient with a fever
b. Patient who is anesthetized
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