Nurs 172 Exam 2 Med-Surge Modules 5 & 6 Exam:
Respiratory Chapters 26, 27, 28, 30, 32, 33, 34 ATI RN adult
medical surgical nursing unit 3 Questions With Complete
Solutions
A 24-year-old male with a gunshot wound to the right side of the
chest walks into the emergency department while leaning on
another young man. The patient exhibits severe shortness of
breath and decreased breath sounds on the right side. Which
action should the nurse take immediately?
a. Cover the chest wound with a nonporous dressing taped on
three sides.
b. Pack the chest wound with sterile saline soaked gauze and
tape securely.
c. Stabilize the chest wall with tape and initiate positive pressure
ventilation.
d. Apply a pressure dressing over the wound to prevent
excessive loss of blood. Correct Answers a. Cover the chest
wound with a nonporous dressing taped on three sides. Correct
The patient has a sucking chest wound (open pneumothorax).
Air enters the pleural space through the chest wall during
inspiration. Emergency treatment consists of covering the
wound with an occlusive dressing that is secured on three sides.
During inspiration the dressing pulls against the wound
preventing air from entering the pleural space. During expiration
the dressing is pushed out and air escapes through the wound
and from under the dressing.
,A 67-year-old male patient had a right total knee replacement 2
days ago. Upon auscultation of the patient's posterior chest, the
nurse detects discontinuous, high-pitched breath sounds just
before the end of inspiration in the lower portion of both lungs.
Which statement most appropriately reflects how the nurse
should document the breath sounds?
A. "Bibasilar rhonchi present on inspiration."
B. "Diminished breath sounds in the bases of both lungs."
C. "Fine crackles posterior right and left lower lung fields."
D. "Expiratory wheezing scattered throughout the lung fields."
Correct Answers "Fine crackles posterior right and left lower
lung fields." Correct
Fine crackles are described as a series of short-duration,
discontinuous, high-pitched sounds heard just before the end of
inspiration.
A 73-year-old female patient who lives alone is admitted to the
hospital with a diagnosis of pneumococcal pneumonia. Which
clinical manifestation, if observed by the nurse, indicates that
the patient is likely to be hypoxic?
a. Sudden onset of confusion
b. Oral temperature of 102.3o F
c. Coarse crackles in lung bases
d. Clutching chest on inspiration Correct Answers Sudden
onset of confusion Correct
Confusion or stupor (related to hypoxia) may be the only clinical
manifestation of pneumonia in an older adult patient. An
elevated temperature, coarse crackles, and pleuritic chest pain
,with guarding may occur with pneumonia, but these symptoms
do not indicate hypoxia.
A frail 82-year-old female patient develops sudden shortness of
breath while sitting in a chair. What location on the chest should
the nurse begin auscultation of the lung fields?
A. Bases of the posterior chest area
B. Apices of the posterior lung fields
C. Anterior chest area above the breasts
D. Midaxillary on the left side of the chest Correct Answers
Bases of the posterior chest area Correct
Baseline data with the most information is best obtained by
auscultation of the posterior chest, especially in female patients
because of breast tissue interfering with the assessment or if the
patient may tire easily (e.g., shortness of breath, dyspnea,
weakness, fatigue). Usually auscultation proceeds from the lung
apices to the bases unless it is possible the patient will tire
easily. In this case the nurse should start at the bases.
A patient had an open reduction repair of a bilateral nasal
fracture. The nurse plans to implement an intervention that
focuses on both nursing and medical goals for this patient.
Which intervention should the nurse implement?
a. Apply an external splint to the nose.
b. Insert plastic nasal implant surgically.
c. Humidify the air for mouth breathing.
d. Maintain surgical packing in the nose. Correct Answers d.
Maintain surgical packing in the nose. Correct
A goal that is common to nursing and medical management of a
patient after rhinoplasty is to prevent the formation of a septal
, hematoma and potential infections resulting from a septal
hematoma. Therefore the nurse helps to keep the nasal packing
in the nose. The packing applies direct pressure to oozing blood
vessels to stop postoperative bleeding. A medical goal includes
realigning the fracture with an external or internal splint. The
nurse helps maintain the airway by humidifying inspired air
because the nose is unable to do so following surgery because it
is swollen and packed with gauze.
A patient is being discharged from the emergency department
after being treated for epistaxis. In teaching the family first aid
measures in the event the epistaxis would recur, what measures
should the nurse suggest (select all that apply)?
a. Tilt patient's head backwards.
b. Apply ice compresses to the nose.
c. Tilt head forward while lying down.
d. Pinch the entire soft lower portion of the nose.
e. Partially insert a small gauze pad into the bleeding nostril.
Correct Answers b. Apply ice compresses to the nose. Correct
d. Pinch the entire soft lower portion of the nose. Correct
First aid measures to control epistaxis include placing the patient
in a sitting position, leaning forward. Pinching the soft lower
portion of the nose or inserting a small gauze pad into the
bleeding nostril should stop the bleeding within 15 minutes.
Tilting the head back or forward does not stop the bleeding, but
rather allows the blood to enter the nasopharynx, which could
result in aspiration or nausea/vomiting from swallowing blood.
Lying down also will not decrease the bleeding.
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