Respiratory test questions 1 - 1. The nurse prepares a patient with a left-sided pleural effusion for a thoracentesis. How should the nurse position the | Course Hero
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1. The nurse prepares a patient with a left-sided pleural effusion for a thoracentesis. How should the nurse position the patient?
a.Supine with the head of the bed elevated 30 degrees b.In a high-Fowler’s position with the left arm extended c.On the right side with the left arm extended above the head d.Sitting upright with the arms supported on an over bed table ANS: D The upright position with the arms supported increases lung expansion, allows fluid to collect at the lung bases, and expands the intercostal space so that access to the pleural space is easier. The other positions would increase the work of breathing for the patient and make it more difficult for the health care provider performing the thoracentesis.
d. Sitting upright with the arms supported on an over bed table
2-1. The nurse completes a shift assessment on a patient admitted in the early phase of heart failure. When auscultating the patient’s lungs, which finding would the nurse mostlikely hear?
a. Continuous rumbling, snoring, or rattling sounds mainly on expiration b.Continuous high-pitched musical sounds on inspiration and expiration c.Discontinuous, high-pitched sounds of short duration heard on inspiration
1
d.A series of long-duration, discontinuous, low-pitched sounds during inspiration ANS: C Fine crackles are likely to be heard in the early phase of heart failure. Fine crackles are discontinuous, high-pitched sounds of short duration heard on inspiration. Rhonchi are continuous rumbling, snoring, or rattling sounds mainly on expiration. Course crackles are a series of long-duration, discontinuous, low-pitched sounds during inspiration. Wheezes are continuous high-pitched musical sounds on inspiration and expiration.
2-2. On auscultation of a patient’s lungs, the nurse hears low-pitched, bubbling sounds during inhalation in the lower third of both lungs. How should the nurse document this finding?
a.Inspiratory crackles at the bases b.Expiratory wheezes in both lungs c. Abnormal lung sounds in the apices of both lungs d.Pleural friction rub in the right and left lower lobes ANS: A 2-3. Crackles are low-pitched, bubbling sounds usually heard on inspiration. Wheezes are high-pitched sounds. They can be heard during the expiratory or inspiratory phase of the respiratory cycle. The lower third of both lungs are the bases, not apices. Pleural friction rubs are grating sounds that are usually heard during both inspiration and expiration.
a. Inspiratory crackles at the bases
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