Nur 195 Test 1 Study Questions and
Answers 2024
Respiratory: What is the nurse's priority? - ANSWERS-A
Airway:
upper
respiratory tract
natural or artificial airway
B
Breathing:
lower
respiratory tract
respiration: ventilation, perfusion, diffusion
C
Circulation: adequate BP and Hemoglobin (Hg)
Morbidly obese - ANSWERS-increase risk for airway and breathing issues, increased
respiratory rate, circulatory issues, etc, DVT- can change into a pulmonary embolism
Head of the bed must be up for - ANSWERS-respiratory patients and the elderly
If patient is unconscious - ANSWERS-keep them on their side in case they vomit
Anything below the trachea is - ANSWERS-sterile
If someone aspirates, what lung will most likely be affected? - ANSWERS-Right lung
PLEURAL EFFUSION - ANSWERS-Addtl fluid in the lung (pleural space)
diaphragm - ANSWERS-the major muscle of respiration located at the base of the
thoracic cavity
use of accessory muscles - ANSWERS-Scalenes, intercostal, flaring of nostrils
Surfactant - ANSWERS-keeps the alveoli open and decreases surface
Atelectasis - ANSWERS-unable to keep the alveoli open (collapsed alveoli), low grade
temp and may have crackles, leads to hospital acquired pneumonia, important to use
incentive spirometer
anatomic dead space - ANSWERS-Nose to bronchioles
,What Controls Respiratory Rate and Depth? - ANSWERS-Chemoreceptors in the Brain,
Peripheral receptors -Carotid and Aortic Bodies, Mechanical receptors in the Lungs
Chemoreceptors in the Brain - ANSWERS---Chemical changes in H+ ion concentration
or pH
--Changes in carbon dioxide concentration
Peripheral receptors -Carotid and Aortic Bodies - ANSWERS-respond to oxygen levels,
carbon dioxide and pH
Mechanical receptors in the Lungs - ANSWERS-Physiologic factors: pulmonary muscle
stretching, alveolar wall distortion, irritants and fluid build up.
Why must COPD patients be conscious of the amt of oxygen that they get? -
ANSWERS-they have higher levels of carbon dioxide
What is a focused respiratory assessment? - ANSWERS-Subjective Assessments:
•Dyspnea: (rated on a scale of 1-10)
•Chest pain: pulmonary v.s. cardiac origin
Objective assessments:
•Cough: describe characteristics
•Sputum: quantity, consistency, color
Physical Assessments:
Inspection, Palpation, Percussion, Auscultation
Arterial Blood Gas (ABG) - ANSWERS-ABG analysis is used to evaluate respiratory
function and provides accurate information about oxygenation, ventilation and acid-base
balance. The measurements reported are the pH, PaCO2, PaO2, HCO3 and SaO2.
An arterial puncture is done from the radial, brachial or femoral artery or the blood is
obtained from an indwelling arterial catheter. Perform the Allen test before using the
radial artery. Use a heparinized syringe and immediately place blood sample on ice and
send to the lab.
Nursing Implications:
Explain the procedure to the patient. Make no changes with the patient for twenty
minutes prior to test. Indicate whether oxygen was in use at the time blood was drawn.
Once the needle is removed, firm, direct pressure is applied for 5 minutes to the arterial
site, until the site is no longer bleeding.
M.H. 72 y/o female admitted with diagnosis of Pneumonia , shortness of breath, fever,
chest pain with coughing, fatigue.
Health History: smoker, Influenza PTA, productive cough
Diagnostics: CXR - RLL infiltrates, consolidation: Pneumonia
Labs: Blood and Sputum cultures pending, WBC: Leukocytosis
Proceed with data collection and the Nursing Process: - ANSWERS-Physical Exam
,Observe or Monitor: WOB, LOC, RR and depth, SpO2, sputum production
Inspect: skin color and temp, nail beds, chest symmetry
Palpate: tactile fremitus
Auscultate: adventitious sounds (cackles), egophony (voice resonance- say the letter A,
if it sounds like E it signifies pneumonia
pulse oximetry - ANSWERS-Nursing implications: values less than 90% indicate
inadequate oxygenation. assess patient's status and presence of factors that could
interfere with accuracy of readings.
Culture and Sensitivity
Gram Stain
Acid-fast smear and culture
Cytology - ANSWERS-Purpose is to identify pathogenic organisms to aid in diagnosis,
selection and evaluation of treatment.
Expectoration is the usual method used to collect sputum in a sterile container after
clearing the nose and throat and rinsing the mouth. Instruct patient to cough forcefully
with exhalation.
Nursing Implications: An early morning specimen is best. Deliver to the lab immediately
to prevent overgrowth of the specimen.
Chest X-Ray
(CXR) - ANSWERS-Test used to screen, diagnose and evaluate changes in the chest.
Most common views are PA and lateral which requires patient transport to Radiology.
Nursing Implications:
The nurse should ensure that the patient has removed jewelry, dentures, all external
metallic objects, and wires
Nursing Implications:
The nurse should ensure that the patient has removed jewelry, dentures, all external
metallic objects, and wires
Computed tomography
(CT) - ANSWERS-This test is performed for diagnosis of lesions difficult to assess by
conventional x-ray studies. Images produced provide a cross-sectional view of the
chest.
Test is done with or without contrast. Contrast media is iodine-based.
Patient may require sedation in order to be able to tolerate the test.
Nursing Implications:
Screen the patient for shellfish or iodine allergies.
Evaluate hydration and renal function.
Determine weight is within limits.
Provides a more detailed diagnostic image and is used for diagnosis of lesions difficult
to assess by CT scan.
Contrast media is not iodine-based.
Magnetic Resonance Imaging
, (MRI) - ANSWERS-Nursing Implications:
Carefully screen the patient for any internal (implants) or external metal which may
restrict patient from having the test.
Ventilation-Perfusion Scan
(V/Q Scan) - ANSWERS-This test is used to assess lung function, vascular supply and
identify areas of the lung not receiving airflow (ventilation) or blood flow (perfusion).
No risk of radioactivity
Nursing Implications: same as CXR
Bronchoscopy (endoscope) - ANSWERS-Invasive procedure using a flexible fiber optic
scope used for direct inspection of the larynx, trachea and bronchi for diagnosis, biopsy,
specimen collection and assessment of changes.
Topical anesthetic and moderate sedation is administered to patient. Therapeutic use of
the procedure includes removal of mucus plugs or foreign objects, difficult endotracheal
intubations and more.
Nursing Implications:
Consent for procedure, remove dentures, NPO before procedure and afterwards until
gag reflex returns. Monitor for possible complications: aspiration, respiratory distress,
hemoptysis,, pneumothorax, hypoxemia. Post-procedure CXR if biopsy performed.
Thoracentesis - ANSWERS-Procedure removes fluid or air from the pleural space,
obtain a specimen from the pleural fluid for analysis or to instill medication into the
pleural space.
Procedure is diagnostic or therapeutic: ease the work of breathing. Ideal positioning is
upright with adequate supports. Local anesthetic to insertion site. Fluid removal no more
than 1.5L.
Nursing Implications:
Consent for procedure. Previous CXR and coagulation studies. Positioning of patient is
vital for good patient outcomes. Post-procedure CXR. Fluid is sent to the lab for studies.
Monitor for complications: pneumothorax, subcutaneous emphysema, pulmonary
edema or cardiac distress
Pulmonary Function Tests - ANSWERS-Test is used to evaluate lung function and
dysfunction. Involves use of spirometry. Used to screen patients for surgery, disease
and response to therapy.
Patient's full cooperation is necessary.
Nursing Implications:
Schedule test prior to meals and use of bronchodilators.
