Medical Surgical Nursing Assessment
Quiz 26 :
Nursing Assessment: Respiratory System
B When a patient has severe respiratory distress,only information pertinent to the current episode is obtained,and a more thorough assessment is deferred until later.Obtaining a comprehensive health history or full physical examination is unnecessary until the acute distress has resolved.Brief questioning and a focused physical assessment should be done rapidly to help determine the cause of the distress and suggest treatment. Checking for allergies is important,but it is not appropriate to complete the entire admission database at this time.The initial respiratory assessment must be completed before any diagnostic tests or interventions can be ordered.
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.
B Kussmaul (deep and rapid)respirations are a compensatory mechanism for metabolic acidosis.The low pH and low bicarbonate result indicate metabolic acidosis.Intercostal retractions,a low oxygen saturation rate,and a decrease in venous O₂ pressure would not be caused by acidosis.