Which assessment finding of the respiratory system does the nurse interpret as abnormal?

The nurse should interpret bronchial breath sounds in the lower lung fields as an abnormal finding. Normally, bronchial sounds are heard only over the trachea and mainstem bronchi. When these harsh, high-pitched sounds are heard in the peripheral lung areas, it indicates that lung tissue has become consolidated or filled with fluid, as seen in conditions such as pneumonia.

Rationale for correct answer:
4. Bronchial breath sounds in the lower lung fields. These sounds are characterized by a loud, tubular quality with a longer expiratory phase. In healthy lungs, the alveoli dampen bronchial sounds, so they should not be heard in the lower fields. Their presence there suggests abnormal air-to-fluid or air-to-solid ratios, typically caused by lung consolidation, atelectasis, or fibrosis. This finding warrants prompt investigation to identify the underlying pathology.

Rationale for incorrect answers:
1. Inspiratory chest expansion of 1 in. Normal chest expansion during inspiration is about 1 inch (2.5 cm) and should be symmetric. This finding is expected and indicates adequate lung inflation.
2. Percussion resonance over the lung bases. Resonance is the normal percussion tone over healthy lung tissue, reflecting air-filled alveoli. It indicates normal lung aeration and is not abnormal.
3. Symmetric chest expansion and contraction. Equal movement of both sides of the chest during breathing reflects normal respiratory mechanics and adequate bilateral lung expansion.

Take-home points:

• Bronchial breath sounds heard in peripheral or lower lung fields are a key sign of abnormal lung consolidation or fluid accumulation.
• Normal findings include resonant percussion tones and symmetric chest expansion.
• Recognizing changes in breath sound location or quality is essential for early detection of respiratory pathology.
• Document abnormal findings clearly and notify the provider for further evaluation, such as imaging or sputum testing.

The primary nursing responsibility after obtaining a blood specimen for arterial blood gases (ABGs) is to take the specimen immediately to the laboratory in an iced container. This prevents ongoing metabolism by red blood cells, which can alter gas values and lead to inaccurate results for pH, PaCO₂, and PaO₂ levels.

Rationale for correct answer:
3. Taking the specimen immediately to the laboratory in an iced container.
ABG samples must be transported on ice to slow down cellular metabolism and preserve the accuracy of gas measurements. Delays or warm temperatures can falsely lower PaO₂ and raise PaCO₂ due to ongoing cellular activity. Prompt delivery ensures valid results for accurate assessment of the patient’s respiratory and metabolic status.

Rationale for incorrect answers:
1. Adding heparin to the blood specimen.
Heparin is already present in the syringe before sampling to prevent clotting; adding more after collection is unnecessary and could dilute the specimen.
2. Applying pressure to the puncture site for 2 full minutes.
Pressure should be applied for at least 5 minutes (or longer if the patient is on anticoagulants) to prevent bleeding or hematoma formation.
4. Avoiding any changes in oxygen intervention for 20 minutes following the procedure.
Oxygen interventions should not be altered before the ABG draw, but this restriction does not apply after the sample has been collected.

Take-home points:

• ABG samples must be iced and promptly delivered to maintain accuracy.
• Heparinized syringes prevent clotting during collection.
• Firm pressure for 5 minutes reduces bleeding risk at the puncture site.
• Accurate ABG results are critical for evaluating oxygenation, ventilation, and acid–base balance.