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Week 5 EAQ
Week 5 EAQ Concepts of Nursing
| Question | Answer |
|---|---|
| Which breath sounds would the nurse consider normal? Select all that apply. | - Loud, high-pitched sound resembling air blowing through a hollow pipe - Soft, low -pitched, gentle, rustling sounds heard over all lung areas except the major bronchi - Medium-pitched sounds heard anteriorly over the mainstem bronchi on either side of |
| The nurse should perform which assessments for a patient complaining of a cough? | Cough sound, sputum production, and pattern |
| Which assessment finding will the nurse expect in a patient who is diagnosed with a mass on the right side of the neck? | Tracheal deviation to the left |
| The nurse must perform which intervention for a patient receiving a pulmonary function test? | Assess the patient for respiratory distress |
| Which condition is associated with tachypnea and clubbing of the fingers? | Chronic hypoxemia |
| Which action should the nurse take when administering and reading the tuberculosis (TB) skin test? | Draw a diagram of the forearm and hand and label the injection sites in the patient' s chart. |
| The nurse expects to note which type of fremitus in a patient with a pneumothorax? | absent |
| Which test will be conducted to confirm the diagnosis of tuberculosis (TB) for a patient experiencing a chronic cough? | Tuberculin test |
| Which conditions may cause a false-negative reaction in a tuberculin test? Select all that apply. | - Anergy/ immunosuppression - Overwhelming tuberculosis (TB) infection - TB infection within 8-10 weeks of exposure |
| A patient may be sent for which test based on the following respiratory assessment information? Inspection - Tachypea and cyanosis Palpation- Increased tactile fremitus left lower lobe Percussion Dullness over left lower lobe Auscultation- Bronchial | chest xray |
| Which diagnosis does the nurse expect based on the following respiratory assessment findings? Inspection - Barrel chest pursed lip breathing Palpation- Diminished excursion Percusussion - Hyperresonance Auscultation - Distant crackles and wheezing | Chronic Obstructive Pulmonary Disease (COPD) |
| Why might a patient with lung cancer develop a pleural effusion? | Lymphatic drainage blocked by malignant cells |
| Which early manifestations of distress will the nurse expect in a patient whose arterial blood gas results show the partial pressure of oxygen (PaO 2) at 65 mm HG and the arterial oxygen saturation (SaO2) at 80%? | Restlessness, tachypnea, tachycardia and diaphoresis |
| The nurse would expect which assessment findings in a patient with late manifestations of inadequate oxygenation? Select all that apply. | - use of accessory muscles - cyanosis and cool, clammy skin - pausing for breath between sentences and words |
| AN older adult may present with which respiratory assessment findings? Select all that apply. | - thicker mucus - decreased chest wall movement - diminished breath sounds, particularly at lung bases |
| Which question will the nurse ask when assessing the nutritional metabolic pattern of a patient with chronic obstructive pulmonary disease (COPD)? | "Have you lost any weight recently?" |
| Which questions will the nurse ask when assessing the effects of a patient's respiratory diagnosis on activity exercise patterns? | - "Do you have trouble walking due to shortness of breath?" - "How many flight of stairs can you walk up before you are short of breath?" |
| In which pattern will the nurse auscultate the chest of a patient with shortness of breath and a respiratory rate of 28 breaths/iin? | starting at the lung bases |
| Which nursing action is the priority for a patient admitted to the hospital with cyanosis, dyspnea, and tachycardia and who is sweating and has cold, clammy skin? | start oxygen therapy |
| Which laboratory parameter indicates that it is unsafe for a patient to undergo a CT scan? | Serum creatinine 3.0 mg/dL |
| LPneumonia will likely present with which breath sounds? | - egophony - bronchophony - whispering pectoriloquy |
| Which diagnosis will the nurse anticipate for a patient who presents with dyspnea, bluish discoloration of the lips, fine crackles on auscultation, and dullness upon percussion of the lung fields? | Pulmonary edema |
Created by:
Brandi Sizemore
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