Management of Impaired Cardiopulmonary Functioning

Every question here, with the answer

1. A nurse assesses a patient who was recently intubated with an endotracheal tube. Inspection shows apparent edema around one collarbone. Which assessment action is most appropriate next?

   1. Teach pursed-lip breathing to reduce air trapping.
   2. Count the apical pulse for a full sixty seconds.
   3. Palpate the area to assess for crispy-feeling crepitus.
   4. Delegate incentive spirometry and have unlicensed assistive personnel document the response.

   Answer: Palpate the area to assess for crispy-feeling crepitus.

   The section gives this exact situation as an indication to palpate for subcutaneous emphysema, which may feel crispy to the fingertips. Pursed-lip breathing, apical pulse assessment, and incentive spirometry may be useful in other situations, but they do not assess the collarbone edema after recent intubation.

2. During a focused respiratory assessment, the nurse identifies several new findings. Which findings require immediate reporting? Select all that apply.

   1. Symmetrical chest expansion
   2. Decreased level of consciousness with restlessness
   3. Absence of adventitious lung sounds
   4. Decreased oxygen saturation
   5. Worsening dyspnea

   Answer: Decreased level of consciousness with restlessness, Decreased oxygen saturation, Worsening dyspnea

   The section lists decreased oxygen saturation (per the threshold or as prescribed), worsening dyspnea, and decreased level of consciousness with restlessness as critical respiratory conditions to report immediately. Symmetrical chest expansion and absence of adventitious lung sounds are expected findings, not urgent abnormalities.

3. A patient being assessed for cardiovascular dysfunction reports new chest pain and worsening shortness of breath. What is the nurse’s priority action?

   1. Reposition the patient and reassess at the end of the shift.
   2. Document the findings and report them to the healthcare provider immediately.
   3. Teach diaphragmatic breathing as the only intervention needed.
   4. Encourage coughing and deep breathing before taking further action.

   Answer: Document the findings and report them to the healthcare provider immediately.

   The section identifies reported chest pain and worsening shortness of breath as critical cardiovascular conditions to report immediately. Breathing techniques and repositioning can support cardiopulmonary care, but they do not replace prompt reporting of these new critical symptoms.

4. A nurse begins a focused subjective cardiovascular assessment for a patient reporting fatigue, indigestion, and leg swelling. Which topics should the nurse include in the focused interview? Select all that apply.

   1. Past medical and family history
   2. Current medications
   3. Percussion findings over the pulmonary cavity
   4. Cardiac risk factors
   5. Reported symptoms

   Answer: Past medical and family history, Current medications, Cardiac risk factors, Reported symptoms

   The focused cardiovascular interview should explore past medical and family history, medications, cardiac risk factors, and symptoms. Percussion of the pulmonary cavity is part of respiratory assessment when further exploration is indicated, not a subjective cardiovascular interview topic.

5. A postoperative patient has an order for incentive spirometry to prevent atelectasis. Which instruction by the nurse is best?

   1. Sit upright, breathe in slowly and deeply through the tubing to raise the piston, hold the breath for five seconds or as tolerated, rest briefly, and repeat ten times every hour while awake.
   2. Use the device only when shortness of breath occurs, then stop after the first successful breath.
   3. Ask unlicensed assistive personnel to decide the frequency and volume goal without nurse monitoring.
   4. Lie flat, exhale forcefully into the tubing, and repeat only once each shift.

   Answer: Sit upright, breathe in slowly and deeply through the tubing to raise the piston, hold the breath for five seconds or as tolerated, rest briefly, and repeat ten times every hour while awake.

   The section describes incentive spirometry as sitting upright, inhaling slowly and deeply through the tubing, holding the breath as tolerated, resting briefly, and repeating ten times every hour while awake. The nurse may delegate the intervention, but the nurse remains responsible for documenting and monitoring frequency and volume.