Assessment of Respiratory Function
The nurse is reviewing the blood gas results for a patient with pneumonia. What arterial blood gas measurement best reflects the adequacy of alveolar ventilation? 1. PaCO2 2. SaO2 3. pH 4. PaO2
Correct response: PaCO2 Explanation: When the minute ventilation falls, alveolar ventilation in the lungs also decreases, and the PaCO2 increases.
The nurse is admitting a client who just had a bronchoscopy. Which assessment should be the nurse's priority? 1. Presence of carotid pulse 2. Medication allergies 3. Ability to deep breathe 4. Swallow reflex
Correct response: Swallow reflex Explanation: The physician sprays a local anesthetic into the client's throat before performing a bronchoscopy. The nurse must assess the swallow reflex when the client returns to the unit and before giving him anything by mouth. The nurse should also assess for medication allergies, carotid pulse, and deep breathing, but they aren't the priority at this time.
While auscultating the lungs of a client with asthma, the nurse hears a continuous, high-pitched whistling sound on expiration. The nurse will document this sound as which of the following? 1. Crackles 2. Rhonchi 3. Pleural friction rub 4. Wheezes
Correct response: Wheezes Explanation: Wheezes, usually heard on expiration, are continuous, musical, high pitched, and whistle-like sounds caused by air passing through narrowed airways. Often, wheezes are associated with asthma.
A patient comes to the emergency department complaining of a knifelike pain when taking a deep breath. What does this type of pain likely indicate to the nurse? 1. Bronchogenic carcinoma 2. Lung infarction 3. Pleurisy 4. Bacterial pneumonia
Correct response: Pleurisy Explanation: Pleuritic pain from irritation of the parietal pleura is sharp and seems to "catch" on inspiration; patients often describe it as being "like the stabbing of a knife." In carcinoma, the pain may be dull and persistent because the cancer has invaded the chest wall, mediastinum, or spine.
Pink, frothy sputum may be an indication of 1. pulmonary edema. 2. an infection. 3. a lung abscess. 4. bronchiectasis.
Correct response: pulmonary edema. Explanation: Profuse frothy, pink material, often welling up into the throat, may indicate pulmonary edema. Foul-smelling sputum and bad breath may indicate a lung abscess, bronchiectasis, or an infection caused by fusospirochetal or other anaerobic organisms.
The volume of air inhaled and exhaled with each breath is termed 1. expiratory reserve volume. 2. tidal volume. 3. vital capacity. 4. residual volume.
Correct response: tidal volume. Explanation: Tidal volume is the volume of air inhaled and exhaled with each breath. Residual volume is the volume of air remaining in the lungs after a maximum expiration. Vital capacity is the maximum volume of air exhaled from the point of maximum inspiration. Expiratory reserve volume is the maximum volume of air that can be exhaled after a normal inhalation.
The volume of air inhaled and exhaled with each breath is termed 1. residual volume. 2. vital capacity. 3. tidal volume. 4. expiratory reserve volume.
Correct response: tidal volume. Explanation: Tidal volume is the volume of air inhaled and exhaled with each breath. Residual volume is the volume of air remaining in the lungs after a maximum expiration. Vital capacity is the maximum volume of air exhaled from the point of maximum inspiration. Expiratory reserve volume is the maximum volume of air that can be exhaled after a normal inhalation.
Which hollow tube transports air from the laryngeal pharynx to the bronchi? .1 larynx 2. bronchioles 3. trachea 4. pharynx
Correct response: trachea Explanation: The trachea is a hollow tube composed of smooth muscle and supported by C-shaped cartilage. The trachea transports air from the laryngeal pharynx to the bronchi and lungs. This is a cartilaginous framework between the pharynx and trachea that produces sound. The bronchioles are smaller subdivisions of bronchi within the lungs. The pharynx, or throat, carries air from the nose to the larynx and food from the mouth to the esophagus.
A nurse understands that a safe but low level of oxygen saturation provides for adequate tissue saturation while allowing no reserve for situations that threaten ventilation. What is a safe but low oxygen saturation level for a patient? 1. 75% 2. 40% 3. 80% 4. 95%
Correct responce: 95% Explanation: With a normal value for the partial pressure of oxygen (PaO2) (80 to 100 mm Hg) and oxygen saturation (SaO2) (95% to 98%), there is a 15% margin of excess oxygen available to the tissues. With a normal hemoglobin level of 15 mg/dL and a PaO2 level of 40 mm Hg (SaO2 75%), there is adequate oxygen available for the tissues but no reserve for physiologic stresses that increase tissue oxygen demand.
The clinical finding of pink, frothy sputum may be an indication of which condition? 1. Lung abscess 2. Bronchiectasis 3. Infection 4. Pulmonary edema
Correct response: Pulmonary edema Explanation: Profuse frothy, pink material, often welling up into the throat, may indicate pulmonary edema. Foul-smelling sputum and bad breath may indicate a lung abscess, bronchiectasis, or an infection caused by fusospirochetal or other anaerobic organisms.
The nurse is caring for a client with an exacerbation of COPD and scheduled for pulmonary function studies using a spirometer. Which client statement would the nurse clarify? 1. "My study is scheduled for 10 AM, several hours after I eat." 2. "I will breathe in through my mouth and out through my nose." 3. "I am ordered a bronchodilator to note lung improvement following use." 4. "I brought comfortable clothes and shoes for the test."
Correct response: "I will breathe in through my mouth and out through my nose." Explanation: The nurse would clarify the client's statement of improper breathing technique. During a pulmonary function test using a spirometer, a nose clip prevents air from escaping through the client's nose when blowing into the spirometer. All other statements are correct.
A nurse is instructing the client on the normal sensations that can occur when contrast medium is infused during pulmonary angiography. Which client statement demonstrates an understanding of the teaching? 1. "I will feel light-headed when the contrast medium is introduced." 2. "I will feel a dull pain when the catheter is introduced." 3. "I will feel warm and may have chest pain" 4. "I will feel waves of nausea throughout the procedure."
Correct response: "I will feel warm and may have chest pain" Explanation: During a pulmonary angiography, a contrast medium is injected into the femoral circulation. When the medium is infused, the client will feel warm and flushed, with a possibility of chest pain. The client will feel pressure when the catheter is inserted. The client does not typically feel light-headed or nauseated during this procedure.
A nurse is instructing the client on the normal sensations that can occur when contrast medium is infused during pulmonary angiography. Which client statement demonstrates an understanding of the teaching? 1. "I will feel light-headed when the contrast medium is introduced." 2. "I will feel a dull pain when the catheter is introduced." 3. "I will feel waves of nausea throughout the procedure." 4. "I will feel warm and may have chest pain"
Correct response: "I will feel warm and may have chest pain" Explanation: During a pulmonary angiography, a contrast medium is injected into the femoral circulation. When the medium is infused, the client will feel warm and flushed, with a possibility of chest pain. The client will feel pressure when the catheter is inserted. The client does not typically feel light-headed or nauseated during this procedure.
When the nurse is assessing the older adult patient, what gerontologic changes in the respiratory system should the nurse be aware of? (Select all that apply.) 1. Increased presence of mucus 2. Decreased gag reflex 3. Increased presence of collagen in alveolar walls 4. Decreased presence of mucus 5. Decreased alveolar duct diameter
Correct response: - Decreased gag reflex - Increased presence of collagen in alveolar walls - Decreased presence of mucus Explanation: Age-related changes in the respiratory system include a decrease in mucus, decrease in gag reflex, increase in collagen in the alveolar walls of the lungs, and increase in alveolar duct diameter.
A nurse would question the accuracy of a pulse oximetry evaluation in which of the following conditions? 1. A client experiencing hypothermia 2. A client sitting in a chair after prolonged bed rest 3. A client receiving oxygen therapy via Venturi mask 4. A client on a ventilator with PEEP
Correct response: A client experiencing hypothermia Explanation: Pulse oximetry is a noninvasive method of continuously monitoring the oxygen saturation of hemoglobin. The reading is referred to as SpO2. A probe or sensor is attached to the fingertip, forehead, earlobe, or bridge of the nose. Values less than 85% indicate that the tissues are not receiving enough oxygen. SpO2 values obtained by pulse oximetry are unreliable in states of low perfusion such as hypothermia.
A nurse working in the radiology clinic is assisting with a client after an unusual arterial procedure. What assessment should the nurse notify the health care provider about? 1. Excessive capillary refill 2. Absent distal pulses 3. Raised temperature in the affected limb 4. Flushed feeling in the client
Correct response: Absent distal pulses Explanation: When monitoring clients after a pulmonary angiography, nurses must notify the health care provider about diminished or absent distal pulses, cool skin temperature in the affected limb, and poor capillary refill. When the contrast medium is infused, the client will sense a warm, flushed feeling.
Your client is scheduled for a bronchoscopy to visualize the larynx, trachea, and bronchi. What precautions would you recommend to the client before the procedure? 1. Avoid sedatives or narcotics as they depress the vagus nerve. 2. Practice holding the breath for short periods. 3. Abstain from food for at least 6 hours before the procedure. 4. Avoid atropines as they dry the secretions.
Correct response: Abstain from food for at least 6 hours before the procedure. Explanation: For at least 6 hours before bronchoscopy, the client must abstain from food or drink to decrease the risk of aspiration. Risk is increased because the client receives local anesthesia, which suppresses the reflexes to swallow, cough, and gag. The client receives medications before the procedure. Typically, atropine is given to dry secretions and a sedative or narcotic is given to depress the vagus nerve. The client may need to hold his or her breath for short periods during lung scans and for bronchoscopy.
Which is a true statement regarding air pressure variances? 1. The diaphragm relaxes during inspiration. 2. The thoracic cavity becomes smaller during inspiration. 3. Air flows from a region of lower pressure to a region of higher pressure during inspiration. 4. Air is drawn through the trachea and bronchi into the alveoli during inspiration.
Correct response: Air is drawn through the trachea and bronchi into the alveoli during inspiration. Explanation: Air flows from a region of higher pressure to a region of lower pressure. During inspiration, movement of the diaphragm and other muscles of respiration enlarge the thoracic cavity, thereby lowering the pressure inside the thorax to a level below that of atmospheric pressure.
A patient visited a health care clinic for treatment of upper respiratory tract congestion, fatigue, and sputum production that was rust-colored. Which of the following diagnoses is likely based on this history and inspection of the sputum? 1. Bronchitis 2. Bronchiectasis 3. An infection with pneumococcal pneumonia 4. A lung abscess
Correct response: An infection with pneumococcal pneumonia Explanation: Sputum that is rust colored suggests infection with pneumococcal pneumonia. Bronchiectasis and a lung abscess usually are associated with purulent thick and yellow-green sputum. Bronchitis usually yields a small amount of purulent sputum.
The nurse is interviewing a patient who says he has a dry, irritating cough that is not "bringing anything up." What medication should the nurse question the patient about taking? 1. Cardiac glycosides 2. Bronchodilators 3. Angiotensin converting enzyme (ACE) inhibitors 4. Aspirin
Correct response: Angiotensin converting enzyme (ACE) inhibitors Explanation: Common causes of cough include asthma, gastrointestinal reflux disease, infection, aspiration, and side effects of medications, such as angiotensin converting enzyme (ACE) inhibitors. The other medications listed are not associated with causing a cough.
The nurse is caring for clients on the neurological unit. Which triad of neurological mechanisms does the nurse identify as most responsible when there is abnormality in ventilation control? 1. Aortic arch, pons, and CO2 receptor sites 2. Medulla oblongata, mitral valve, and central receptors 3. Pons, cerebellum, and oxygen receptors 4. Medulla oblongata, cerebellum, and heart rate
Correct response: Aortic arch, pons, and CO2 receptor sites Explanation: Several mechanisms control ventilation. The respiratory center in the medulla oblongata and pons control rate and depth of respirations. The central chemo receptors in the medulla and peripheral chemo receptors in the aortic arch also provide a mechanism for detecting abnormalities and signal changes to alter the pH and levels of oxygen in the blood. The other options have an incorrect piece of the triad.
A nonverbal client has just finished undergoing a bronchoscopy procedure and writes that he want to eat lunch now. Which intervention is necessary for the nurse to complete at this time? 1. Perform mouth care. 2. Assess for a cough reflex. 3. Assess for bowel sounds. 4. Call dietary services to send the client's tray now.
Correct response: Assess for a cough reflex. Explanation: Before a bronchoscopy procedure, the nurse will administer preoperative medications, usually atropine and a sedative. These are prescribed to inhibit vagal stimulation, suppress the cough reflex, sedate the client, and relieve anxiety. After the procedure, it is important that the client take nothing by moth until the cough reflex returns. This is because the preoperative medication impairs the protective laryngeal reflex and swallowing for several hours. Once the client demonstrates a cough reflex or the nurse positively assesses one, then the nurse may offer ice chips and fluids.
The nurse assessed a 28-year-old woman who was experiencing dyspnea severe enough to make her seek medical attention. The history revealed no prior cardiac problems and the presence of symptoms for 6 months' duration. On assessment, the nurse noted the presence of both inspiratory and expiratory wheezing. Based on this data, which of the following diagnoses is likely? 1. Acute respiratory obstruction 2. Adult respiratory distress syndrome 3. Asthma 4. Pneumothorax
Correct response: Asthma Explanation: The presence of both inspiratory and expiratory wheezing usually signifies asthma if the individual does not have heart failure. Sudden dyspnea is an indicator of the other choices.
The nurse assessed a 28-year-old woman who was experiencing dyspnea severe enough to make her seek medical attention. The history revealed no prior cardiac problems and the presence of symptoms for 6 months' duration. On assessment, the nurse noted the presence of both inspiratory and expiratory wheezing. Based on this data, which of the following diagnoses is likely? 1. Acute respiratory obstruction 2. Adult respiratory distress syndrome 3. Pneumothorax 4. Asthma
Correct response: Asthma Explanation: The presence of both inspiratory and expiratory wheezing usually signifies asthma if the individual does not have heart failure. Sudden dyspnea is an indicator of the other choices.
What finding by the nurse may indicate that the client has chronic hypoxia? 1. Clubbing of the fingers 2. Peripheral edema 3. Cyanosis 4. Crackles
Correct response: Clubbing of the fingers Explanation: Clubbing of the fingers is a change in the normal nail bed. It appears as sponginess of the nail bed and loss of the nail bed angle. It is a sign of lung disease that is found in patients with chronic hypoxic conditions, chronic lung infections, or malignancies of the lung. Cyanosis can be a very late indicator of hypoxia, but it is not a reliable sign of hypoxia. The other signs listed may represent only a temporary hypoxia.
What finding by the nurse may indicate that the client has chronic hypoxia? 1. Cyanosis 2. Crackles 3. Peripheral edema 4. Clubbing of the fingers
Correct response: Clubbing of the fingers Explanation: Clubbing of the fingers is a change in the normal nail bed. It appears as sponginess of the nail bed and loss of the nail bed angle. It is a sign of lung disease that is found in patients with chronic hypoxic conditions, chronic lung infections, or malignancies of the lung. Cyanosis can be a very late indicator of hypoxia, but it is not a reliable sign of hypoxia. The other signs listed may represent only a temporary hypoxia.
What finding by the nurse may indicate that the client has chronic hypoxia? 1. Peripheral edema 2. Cyanosis 3. Clubbing of the fingers 4. Crackles
Correct response: Clubbing of the fingers Explanation: Clubbing of the fingers is a change in the normal nail bed. It appears as sponginess of the nail bed and loss of the nail bed angle. It is a sign of lung disease that is found in patients with chronic hypoxic conditions, chronic lung infections, or malignancies of the lung. Cyanosis can be a very late indicator of hypoxia, but it is not a reliable sign of hypoxia. The other signs listed may represent only a temporary hypoxia.
A client arrives in the emergency department reporting shortness of breath. She has 3+ pitting edema below the knees, a respiratory rate of 36 breaths per minute, and heaving respirations. The nurse auscultates the client's lungs to reveal coarse, moist, high-pitched, and non-continuous sounds that do not clear with coughing. The nurse will document these sounds as which type? 1. Wheezes 2. Rhonchi 3. Crackles 4. Pleural rub
Correct response: Crackles Explanation: Crackles are adventitious breath sounds that are high-pitched, discontinuous, and popping; they may or may not clear with coughing and are moist. Often crackles are associated with heart failure.
The nurse is assessing a patient in respiratory failure. What finding is a late indicator of hypoxia? 1. Crackles 2. Clubbing of fingers 3. Restlessness 4. Cyanosis
Correct response: Cyanosis Explanation: Cyanosis, a bluish coloring of the skin, is a very late indicator of hypoxia. The presence or absence of cyanosis is determined by the amount of unoxygenated hemoglobin in the blood. Cyanosis appears when there is at least 5 g/dL of unoxygenated hemoglobin.
The nurse is caring for a patient with a pulmonary disorder. What observation by the nurse is indicative of a very late symptom of hypoxia? 1. Cyanosis 2. Restlessness 3. Confusion 4. Dyspnea
Correct response: Cyanosis Explanation: Cyanosis, a bluish coloring of the skin, is a very late indicator of hypoxia. The presence or absence of cyanosis is determined by the amount of unoxygenated hemoglobin in the blood. Cyanosis appears when there is at least 5 g/dL of unoxygenated hemoglobin.
A son brings his father into the clinic, stating that his father's color has changed to bluish around the mouth. The father is confused, with a respiratory rate of 28 breaths per minute and scattered crackles throughout. The son states this condition just occurred within the last hour. Which of the following factors indicates that the client's condition has lasted for more than 1 hour? 1. Son's statement 2. Crackles 3. Respiratory rate 4. Cyanosis
Correct response: Cyanosis Explanation: The client's appearance may give clues to respiratory status. Cyanosis, a bluish coloring of the skin, is a very late indicator of hypoxia. The presence of cyanosis is from decreased unoxygenated hemoglobin. In the presence of a pulmonary condition, cyanosis is assessed by observing the color of the tongue and lips.
For air to enter the lungs (process of ventilation), the intrapulmonary pressure must be less than atmospheric pressure so air can be pulled inward. Select the movement of respiratory muscles that makes this happen during inspiration. 1. Diaphragm contracts and elongates the chest cavity. 2. Anteroposterior rib diameter decreases. 3. Lungs are pulled up and pushed back against the thoracic cage. 4. Intercostals muscles relax to allow for expansion.
Correct response: Diaphragm contracts and elongates the chest cavity. Explanation: The diaphragm contracts during inspiration and pulls the lungs in a downward and forward direction. The abdomen appears to enlarge because the abdominal contents are being compressed by the diaphragm. With inspiration, the diaphragmatic pull elongates the chest cavity, and the external intercostal muscles (located between and along the lower borders of the ribs) contract to raise the ribs, which expands the anteroposterior diameter. The effect of these movements is to decrease the intrapulmonary pressure.
For air to enter the lungs (process of ventilation), the intrapulmonary pressure must be less than atmospheric pressure so air can be pulled inward. Select the movement of respiratory muscles that makes this happen during inspiration. 1. Intercostals muscles relax to allow for expansion. 2. Diaphragm contracts and elongates the chest cavity. 3. Lungs are pulled up and pushed back against the thoracic cage. 4. Anteroposterior rib diameter decreases.
Correct response: Diaphragm contracts and elongates the chest cavity. Explanation: The diaphragm contracts during inspiration and pulls the lungs in a downward and forward direction. The abdomen appears to enlarge because the abdominal contents are being compressed by the diaphragm. With inspiration, the diaphragmatic pull elongates the chest cavity, and the external intercostal muscles (located between and along the lower borders of the ribs) contract to raise the ribs, which expands the anteroposterior diameter. The effect of these movements is to decrease the intrapulmonary pressure.
A client arrives at the physician's office stating dyspnea; a productive cough for thick, green sputum; respirations of 28 breaths/minute, and a temperature of 102.8° F. The nurse auscultates the lung fields, which reveal poor air exchange in the right middle lobe. The nurse suspects a right middle lobe pneumonia. To be consistent with this anticipated diagnosis, which sound, heard over the chest wall when percussing, is anticipated? 1. Dull 2. Tympanic 3. Resonant 4. Hyperresonant
Correct response: Dull Explanation: A dull percussed sound, heard over the chest wall, is indicative of little or no air movement in that area of the lung. Lung consolidation such as in pneumonia or fluid accumulation produces the dull sound. A tympanic sound is a high-pitched sound commonly heard over the stomach or bowel. A resonant sound is noted over normal lung tissue. A hyper resonant sound is an abnormal lower pitched sound that occurs when free air exists in disease processes such as pneumothorax.
High or increased compliance occurs in which disease process? 1. ARDS 2. Emphysema 3. Pleural effusion 4. Pneumothorax
Correct response: Emphysema Explanation: High or increased compliance occurs if the lungs have lost their elasticity and the thorax is overdistended, as in emphysema. Conditions associated with decreased compliance include pneumothorax, pleural effusion, and acute respiratory distress syndrome (ARDS).
During a routine visit to the pulmonologist, a client is told to undergo a mediastinoscopy. After the physician leaves the room, the nurse enters and is asked about this procedure. How should the nurse respond? 1. Exploration and biopsy of the lymph nodes that drain the lungs 2. Injection of radioactive dye to measure the integrity of the lung's blood flow 3. Aspiration of the fluid that has accumulated around the lungs 4. Inspection and examination of the larynx, trachea, and bronchi
Correct response: Exploration and biopsy of the lymph nodes that drain the lungs Explanation: A mediastinoscopy is the endoscopic examination of the mediastinum for exploration and biopsy of mediastinal lymph nodes that drain the lungs. The remaining options are explanations of other pulmonary diagnostic studies.
A nurse is obtaining a health history from a client who reports hemoptysis for the past 2 months. The client reports occasional dyspnea. Which imaging study, ordered by the physician, will view the thoracic cavity while in motion? 1. Fluoroscopy 2. Magnetic resonance imaging (MRI) 3. Chest x-ray 4. Computed tomography (CT) scan
Correct response: Fluoroscopy Explanation: Fluoroscopy enables the physician to view the thoracic cavity with all of its contents in motion. A fluoroscopy more precisely diagnoses the location of a tumor or lesion. An x-ray shows the size, shape, and position of the lungs. An MRI and CT produce axial views of the lungs.
A client with sinus congestion complains of discomfort when the nurse is palpating the supraorbital ridges. What sinus is the client referring? 1. Ethmoidal 2. Frontal 3. Sphenoidal 4. Maxillary
Correct response: Frontal Explanation: The nurse may palpate the frontal and maxillary sinuses for tenderness. Using the thumbs, the nurse applies gentle pressure in an upward fashion at the supraorbital ridges (frontal sinuses) and in the cheek area adjacent to the nose (maxillary sinuses). The ethmoidal sinuses are located between the nose and eyes. The sphenoidal sinuses are behind the nose between the eyes.
On arrival at the intensive care unit, a critically ill client suffers respiratory arrest and is placed on mechanical ventilation. The physician orders pulse oximetry to monitor the client's arterial oxygen saturation (SaO2) noninvasively. Which vital sign abnormality may alter pulse oximetry values? 1. Tachypnea 2. Fever 3. Tachycardia 4. Hypotension
Correct response: Hypotension Explanation: Hypotension, hypothermia, and vasoconstriction may alter pulse oximetry values by reducing arterial blood flow. Likewise, movement of the finger to which the oximeter is applied may interfere with interpretation of SaO2. All of these conditions limit the usefulness of pulse oximetry. Fever, tachypnea, and tachycardia don't affect pulse oximetry values directly.
A nurse is concerned that a client may develop postoperative atelectasis. Which nursing diagnosis would be most appropriate if this complication occurs? 1. Impaired gas exchange 2. Decreased cardiac output 3. Impaired spontaneous ventilation 4. Ineffective airway clearance
Correct response: Impaired gas exchange Explanation: Airflow is decreased with atelectasis, which is a bronchial obstruction from collapsed lung tissue. If there is an obstruction, there is limited or no gas exchange in this area. Impaired gas exchange is thus the most likely nursing diagnosis with atelectasis.
A nurse is concerned that a client may develop postoperative atelectasis. Which nursing diagnosis would be most appropriate if this complication occurs? 1. Ineffective airway clearance 2. Impaired gas exchange 3. Impaired spontaneous ventilation 4. Decreased cardiac output
Correct response: Impaired gas exchange Explanation: Airflow is decreased with atelectasis, which is a bronchial obstruction from collapsed lung tissue. If there is an obstruction, there is limited or no gas exchange in this area. Impaired gas exchange is thus the most likely nursing diagnosis with atelectasis.
What would the instructor tell the students purulent fluid indicates? 1. Infection 2. Heart failure 3. Inflammation 4. Cancer
Correct response: Infection Explanation: A small amount of fluid lies between the visceral and parietal pleurae. When excess fluid or air accumulates, the physician aspirates it from the pleural space by inserting a needle into the chest wall. This procedure, called thoracentesis, is performed with local anesthesia. Thoracentesis also may be used to obtain a sample of pleural fluid or a biopsy specimen from the pleural wall for diagnostic purposes such as a culture, sensitivity, or microscopic examination. Purulent fluid is the recommended diagnosis for infection. Serous fluid may be associated with cancer, inflammatory conditions, or heart failure.
What would the instructor tell the students purulent fluid indicates? 1. Inflammation 2. Heart failure 3. Infection 4. Cancer
Correct response: Infection Explanation: A small amount of fluid lies between the visceral and parietal pleurae. When excess fluid or air accumulates, the physician aspirates it from the pleural space by inserting a needle into the chest wall. This procedure, called thoracentesis, is performed with local anesthesia. Thoracentesis also may be used to obtain a sample of pleural fluid or a biopsy specimen from the pleural wall for diagnostic purposes such as a culture, sensitivity, or microscopic examination. Purulent fluid is the recommended diagnosis for infection. Serous fluid may be associated with cancer, inflammatory conditions, or heart failure.
The nurse is in the radiology unit of the hospital. The nurse is caring for a client who is scheduled for a lung scan. The nurse knows that lung scans need the use of radioisotopes and a scanning machine. Before the perfusion scan, what must the client be assessed for? 1. Bleeding 2. Dysrhythmias 3. Iodine allergy 4. Inflammation
Correct response: Iodine allergy Explanation: During lung scans, a radioactive contrast medium is administered intravenously for the perfusion scan. Before the perfusion scan, nurses must assess the client to check for allergies to iodine. Laryngoscopy determines inflammation. Dysrhythmias and bleeding are possible complications of mediastinoscopy.
A client has a nursing diagnosis of "ineffective airway clearance" as a result of excessive secretions. An appropriate outcome for this client would be which of the following? 1. Client can perform incentive spirometry. 2. Client reports no chest pain. 3. Respiratory rate is 12 to 18 breaths per minute. 4. Lungs are clear on auscultation.
Correct response: Lungs are clear on auscultation. Explanation: Assessment of lung sounds includes auscultation for airflow through the bronchial tree. The nurse evaluates for fluid or solid obstruction in the lung. When airflow is decreased, as with fluid or secretions, adventitious sounds may be auscultated. Often crackles are heard with fluid in the airways.
The student nurse is learning breath sounds while listening to a client in the physician's office. An experienced nurse is assisting and notes air movement over the trachea to the upper lungs. The air movement is noted equally on inspiration as expiration. Which breath sounds would the nurse document? 1. Normal bronchial sounds 2. Abnormal bronchial sounds 3. Abnormal vesicular sounds 4. Normal bronchovesicular sounds
Correct response: Normal bronchovesicular sounds Explanation: Air movement over the trachea and upper lungs is a normal finding for bronchovesicular sounds. The air movement is noted equally on inspiration as expiration. The other choices do not match type of breath sound for the location in question.
The nurse is performing an assessment for a patient with congestive heart failure. The nurse asks if the patient has difficulty breathing in any position other than upright. What is the nurse referring to? 1. Bradypnea 2. Orthopnea 3. Tachypnea 4. Dyspnea
Correct response: Orthopnea Explanation: Orthopnea (inability to breathe easily except in an upright position) may be found in patients with heart disease and occasionally in patients with chronic obstructive pulmonary disease (COPD). Dyspnea (subjective feeling of difficult or labored breathing, breathlessness, shortness of breath) is a multidimensional symptom common to many pulmonary and cardiac disorders, particularly when there is decreased lung compliance or increased airway resistance. Tachypnea is abnormally rapid respirations. Bradypnea is abnormally slow respirations.
A patient exhibited signs of an altered ventilation-perfusion ratio. The nurse is aware that adequate ventilation but impaired perfusion exists when the patient has which of the following conditions? 1. Infective process 2. Tumor 3. Atelectasis 4. Pulmonary embolism
Correct response: Pulmonary embolism Explanation: When a blood clot exists in a pulmonary vessel (embolus), impaired perfusion results. However, ventilation is adequate. With the other choices, ventilation is impaired but perfusion is adequate.
The nurse is caring for a client whose respiratory status has declined since shift report. The client has tachypnea, is restless, and displays cyanosis. Which diagnostic test should be assessed first? 1. Chest x-ray 2. Arterial blood gases 3. Pulmonary function test 4. Pulse oximetry
Correct response: Pulse oximetry Explanation: Pulse oximetry is a noninvasive method to determine arterial oxygen saturation. Normal values are 95% and above. Using this diagnostic test first provides rapid information of the client's respiratory system. All other options vary in amount of time and patient participation in determining further information regarding the respiratory system.
A client with chronic bronchitis is admitted to the health facility. Auscultation of the lungs reveals low-pitched, rumbling sounds. Which term should the nurse document? 1. Pleural friction rub 2. Bronchial 3. Crackles 4. Rhonchi
Correct response: Rhonchi Explanation: Rhonchi or sonorous wheezes are deep, low-pitched, rumbling sounds heard usually on expiration. The etiology of rhonchi is associated with chronic bronchitis. Crackles are soft, high-pitched sounds. Pleural friction rub is a creaking or grating sound not affected by coughing. Bronchial sounds are relatively high-pitched sounds.
A client with chronic bronchitis is admitted to the health facility. Auscultation of the lungs reveals low-pitched, rumbling sounds. What breath sound should the nurse document? 1. Rhonchi 2. Venous hum 3. Rales 4. Bronchovesicular
Correct response: Rhonchi Explanation: Rhonchi or sonorous wheezes are deep, low-pitched, rumbling sounds heard usually on expiration. The etiology of rhonchi is associated with chronic bronchitis. Rales or crackles are soft, high-pitched sounds. A venous hum is a blood flow humming sound. Bronchovesicular sound is an intermediate pitch with expiration and inspiration.
A client with chronic bronchitis is admitted to the health facility. Auscultation of the lungs reveals low-pitched, rumbling sounds. What breath sound should the nurse document? 1. Venous hum 2. Rales 3. Bronchovesicular 4. Rhonchi
Correct response: Rhonchi Explanation: Rhonchi or sonorous wheezes are deep, low-pitched, rumbling sounds heard usually on expiration. The etiology of rhonchi is associated with chronic bronchitis. Rales or crackles are soft, high-pitched sounds. A venous hum is a blood flow humming sound. Bronchovesicular sound is an intermediate pitch with expiration and inspiration.
In which position should the client be placed for a thoracentesis? 1. Sitting on the edge of the bed 2. Prone 3. Lateral recumbent 4. Supine
Correct response: Sitting on the edge of the bed Explanation: If possible, place the client upright or sitting on the edge of the bed with the feet supported and arms and head on a padded over-the-bed table. Other positions in which the client could be placed include straddling a chair with the arms and head resting on the back of the chair, or lying on the unaffected side with the head of the bed elevated 30 to 45 degrees (if the client is unable to assume a sitting position).
In which position should the client be placed for a thoracentesis? 1. Supine 2. Lateral recumbent 3. Sitting on the edge of the bed 4. Prone
Correct response: Sitting on the edge of the bed Explanation: If possible, place the client upright or sitting on the edge of the bed with the feet supported and arms and head on a padded over-the-bed table. Other positions in which the client could be placed include straddling a chair with the arms and head resting on the back of the chair, or lying on the unaffected side with the head of the bed elevated 30 to 45 degrees (if the client is unable to assume a sitting position).
The nurse is admitting a client who just had a bronchoscopy. Which assessment should be the nurse's priority? 1. Swallow reflex 2. Ability to deep breathe 3. Medication allergies 4. Presence of carotid pulse
Correct response: Swallow reflex Explanation: The physician sprays a local anesthetic into the client's throat before performing a bronchoscopy. The nurse must assess the swallow reflex when the client returns to the unit and before giving him anything by mouth. The nurse should also assess for medication allergies, carotid pulse, and deep breathing, but they aren't the priority at this time.
The nurse receives an order to obtain a sputum sample from a client with hemoptysis. When advising the client of the physician's order, the client states not being able to produce sputum. Which suggestion, offered by the nurse, is helpful in producing the sputum sample? 1. Drink 8 oz of water to thin the secretions for expectoration. 2. Take deep breaths and cough forcefully. 3. Use the secretions present in the oral cavity. 4. Tickle the back of the throat to produce the gag reflex.
Correct response: Take deep breaths and cough forcefully. Explanation: Taking deep breaths moves air around the sputum and coughing forcefully moves the sputum up the respiratory tract. Once in the pharynx, the sputum can be expectorated into a specimen container. Producing a gag reflex elicits stomach contents and not respiratory sputum. Dilute and thinned secretions are not helpful in aiding expectoration. A sputum culture is not a component of oral secretions.
Which homeostatic mechanism would the body of a critically ill client use to maintain normal pH? 1. The lungs eliminate carbonic acid by blowing off more CO2. 2. The kidneys retain more HCO3 to raise the pH. 3. The lungs increase respiratory volume. 4. The lungs retain more CO2 to lower the pH.
Correct response: The lungs eliminate carbonic acid by blowing off more CO2. Explanation: To maintain normal pH in critically ill clients, the lungs eliminate carbonic acid by blowing off more CO2. To maintain normal pH in critically ill clients, the lungs conserve CO2 by slowing respiratory volume. The lungs would retain more CO2 during an acid-base imbalance in cases of metabolic alkalosis. The kidneys would retain more HCO3 to compensate during an acid-base imbalance in cases of metabolic acidosis.
Which homeostatic mechanism would the body of a critically ill client use to maintain normal pH? 1. The lungs increase respiratory volume. 2. The lungs retain more CO2 to lower the pH. 3. The kidneys retain more HCO3 to raise the pH. 4. The lungs eliminate carbonic acid by blowing off more CO2.
Correct response: The lungs eliminate carbonic acid by blowing off more CO2. Explanation: To maintain normal pH in critically ill clients, the lungs eliminate carbonic acid by blowing off more CO2. To maintain normal pH in critically ill clients, the lungs conserve CO2 by slowing respiratory volume. The lungs would retain more CO2 during an acid-base imbalance in cases of metabolic alkalosis. The kidneys would retain more HCO3 to compensate during an acid-base imbalance in cases of metabolic acidosis.
The client is returning from the operating room following a bronchoscopy. Which action, performed by the nursing assistant, would the nurse stop if began prior to nursing assessment? 1. The nursing assistant is asking a question requiring a verbal response. 2. The nursing assistant is assisting the client to the side of the bed to use a urinal. 3. The nursing assistant is assisting the client to a semi-Fowler's position. 4. The nursing assistant is pouring a glass of water to wet the client's mouth.
Correct response: The nursing assistant is pouring a glass of water to wet the client's mouth. Explanation: When completing a procedure which sends a scope down the throat, the gag reflex is anesthetized to reduce discomfort. Upon returning to the nursing unit, the gag reflex must be assessed before providing any food or fluids to the client. The client may need assistance following the procedure for activity and ambulation but this is not restricted in the post procedure period.
In relation to the structure of the larynx, which describes the cricoid cartilage? 1. The only complete cartilaginous ring in the larynx 2. The valve flap of cartilage that covers the opening to the larynx during swallowing 3. Used with the thyroid cartilage in vocal cord movement 4. The largest of the cartilage structures
Correct response: The only complete cartilaginous ring in the larynx Explanation: The cricoid cartilage is the only complete cartilaginous ring in the larynx (located below the thyroid cartilage). The arytenoid cartilages are used with the thyroid cartilage in vocal cord movement. The thyroid cartilage is the largest of the cartilage structures; part of it forms the Adam's apple. The epiglottis is the valve flap of cartilage that covers the opening to the larynx during swallowing.
A client experiences a head injury in a motor vehicle accident. The client's level of consciousness is declining, and respirations have become slow and shallow. When monitoring a client's respiratory status, which area of the brain would the nurse realize is responsible for the rate and depth? 1. Central sulcus 2. The pons 3. Wernicke's area 4. The frontal lobe
Correct response: The pons Explanation: The inspiratory and expiratory centers in the medulla oblongata and pons control the rate and depth of ventilation. When injury occurs or increased intracranial pressure results, respirations are slowed. The frontal lobe completes executive functions and cognition. The central sulcus is a fold in the cerebral cortex called the central fissure. The Wernicke's area is the area linked to speech.
The nurse is caring for a client diagnosed with asthma. While performing the shift assessment, the nurse auscultates breath sounds including sibilant wheezes, which are continuous musical sounds. What characteristics describe sibilant wheezes? 1. They occur when the pleural surfaces are inflamed. 2. They result from air passing through widened air passages. 3. They can be heard during inspiration and expiration. 4. They are heard in clients with decreased secretions.
Correct response: They can be heard during inspiration and expiration. Explanation: Sibilant or hissing or whistling wheezes are continuous musical sounds that can be heard during inspiration and expiration. They result from air passing through narrowed or partially obstructed air passages and are heard in clients with increased secretions. The crackling or grating sounds heard during inspiration or expiration are friction rubs. They occur when the pleural surfaces are inflamed.
A nurse is assessing a client's respiratory system. Which alveolar cells secrete surfactant to reduce lung surface tension? 1. Type I 2. Type II 3. Type IV 4. Macrophages
Correct response: Type II Explanation: There are three types of alveolar cells. Type I and type II cells make up the alveolar epithelium. Type I cells account for 95% of the alveolar surface area and serve as a barrier between the air and the alveolar surface; type II cells account for only 5% of this area but are responsible for producing type I cells and surfactant. Surfactant reduces surface tension, thereby improving overall lung function. Alveolar macrophages, the third type of alveolar cells, are phagocytic cells that ingest foreign matter and, as a result, provide an important defense mechanism. Type IV is not a category of alveolar cells.
A nurse is assessing a client's respiratory system. Which alveolar cells secrete surfactant to reduce lung surface tension? 1. Type I 2. Type IV 3. Type II 4. Macrophages
Correct response: Type II Explanation: There are three types of alveolar cells. Type I and type II cells make up the alveolar epithelium. Type I cells account for 95% of the alveolar surface area and serve as a barrier between the air and the alveolar surface; type II cells account for only 5% of this area but are responsible for producing type I cells and surfactant. Surfactant reduces surface tension, thereby improving overall lung function. Alveolar macrophages, the third type of alveolar cells, are phagocytic cells that ingest foreign matter and, as a result, provide an important defense mechanism. Type IV is not a category of alveolar cells.
A nurse is discussing squamous epithelial cells lining each alveolus, which consist of different types of cells. Which type of alveolar cells produce surfactant? 1. Type III cells 2. Type I cells 3. Type IV cells 4. Type II cells
Correct response: Type II cells Explanation: There are three types of alveolar cells. Type I and type II cells make up the alveolar epithelium. Type I cells account for 95% of the alveolar surface area and serve as a barrier between the air and the alveolar surface; type II cells account for only 5% of this area, but are responsible for producing type I cells and surfactant. Surfactant reduces surface tension, thereby improving overall lung function. Alveolar macrophages, the third type of alveolar cells, are phagocytic cells that ingest foreign matter and, as a result, provide an important defense mechanism. The epithelium of the alveoli does not contain Type IV cells.
A nurse is discussing squamous epithelial cells lining each alveolus, which consist of different types of cells. Which type of alveolar cells produce surfactant? 1. Type IV cells 2. Type I cells 3. Type III cells 4. Type II cells
Correct response: Type II cells Explanation: There are three types of alveolar cells. Type I and type II cells make up the alveolar epithelium. Type I cells account for 95% of the alveolar surface area and serve as a barrier between the air and the alveolar surface; type II cells account for only 5% of this area, but are responsible for producing type I cells and surfactant. Surfactant reduces surface tension, thereby improving overall lung function. Alveolar macrophages, the third type of alveolar cells, are phagocytic cells that ingest foreign matter and, as a result, provide an important defense mechanism. The epithelium of the alveoli does not contain Type IV cells.
What is the difference between respiration and ventilation? 1. Ventilation is the exchange of gases in the lung. 2. Ventilation is the process of getting oxygen to the cells. 3. Ventilation is the movement of air in and out of the respiratory tract. 4. Ventilation is the process of gas exchange.
Correct response: Ventilation is the movement of air in and out of the respiratory tract. Explanation: Ventilation is the actual movement of air in and out of the respiratory tract. Respiration is the exchange of oxygen and CO2 between atmospheric air and the blood and between the blood and the cells.
What is the difference between respiration and ventilation? 1. Ventilation is the process of gas exchange. 2. Ventilation is the movement of air in and out of the respiratory tract. 3. Ventilation is the process of getting oxygen to the cells. 4. Ventilation is the exchange of gases in the lung.
Correct response: Ventilation is the movement of air in and out of the respiratory tract. Explanation: Ventilation is the actual movement of air in and out of the respiratory tract. Respiration is the exchange of oxygen and CO2 between atmospheric air and the blood and between the blood and the cells. Therefore, options A, C, and D are incorrect.
What is the purpose of the vascular and ciliated mucous lining of the nasal cavities? 1. Moisten and filter expired air 2. Warm and humidify inspired air 3. Move mucus to the back of the throat 4. Cool and dry expired air
Correct response: Warm and humidify inspired air Explanation: The vascular and ciliated mucous lining of the nasal cavities warms and humidifies inspired air. It is the function of the cilia alone to move mucus in the nasal cavities and filter the inspired air.
The nurse is caring for a client with a decrease in airway diameter causing airway resistance. The client experiences coughing and mucus production. Upon lung assessment, which adventitious breath sounds are anticipated? 1. Wheezes 2. Crackles 3. Rhonchi 4. Rubs
Correct response: Wheezes Explanation: A decrease in airway diameter, such as in asthma, produces breath sounds of wheezes. Wheezes are a whistling type of sound relating to the narrowing on the airway. A wheeze can have a high-pitched or low-pitched quality. Crackles, also noted as rales, are crackling or rattling sounds signifying fluid or exudate in the lung fields. Rhonchi are a course rattling sound similar to snoring usually caused by secretion in the bronchial tree. Rubs are secretions that can be heard in the large airway.
The nurse is performing chest auscultation for a patient with asthma. How does the nurse describe the high-pitched, sibilant, musical sounds that are heard? 1. Rales 2. Crackles 3. Wheezes 4. Rhonchi
Correct response: Wheezes Explanation: Sibilant wheezes are continuous, musical, high-pitched, whistle-like sounds heard during inspiration and expiration caused by air passing through narrowed or partially obstructed airways; they may clear with coughing. Crackles, formerly called rales, are soft, high-pitched, discontinuous popping sounds that occur during inspiration (while usually heard on inspiration, they may also be heard on expiration); they may or may not be cleared by coughing. Rhonchi, or sonorous wheezes, are deep, low-pitched rumbling sounds heard primarily during expiration; they are caused by air moving through narrowed tracheobronchial passages.
A client is being seen in the pediatric clinic for a middle ear infection. The client's mother reports that when the client develops an upper respiratory infection, an ear infection seems quick to follow. What contributes to this event? 1. genetics 2. epiglottis 3. oropharynx 4. eustachian tubes
Correct response: eustachian tubes Explanation: The nasopharynx contains the adenoids and openings of the eustachian tubes. The eustachian tubes connect the pharynx to the middle ear and are the means by which upper respiratory infections spread to the middle ear. The client's infection is not caused by genetics. The oropharynx contains the tongue. The epiglottis closes during swallowing and relaxes during respiration.
A black client with asthma seeks emergency care for acute respiratory distress. Because of this client's dark skin, the nurse should assess for cyanosis by inspecting the: 1. lips. 2. earlobes. 3. mucous membranes. 4. nail beds.
Correct response: mucous membranes. Explanation: Skin color doesn't affect the mucous membranes. Therefore, the nurse can assess for cyanosis by inspecting the client's mucous membranes. The lips, nail beds, and earlobes are less-reliable indicators of cyanosis because they're affected by skin color.
Pink, frothy sputum may be an indication of 1. an infection. 2. bronchiectasis. 3. pulmonary edema. 4. a lung abscess.
Correct response: pulmonary edema. Explanation: Profuse frothy, pink material, often welling up into the throat, may indicate pulmonary edema. Foul-smelling sputum and bad breath may indicate a lung abscess, bronchiectasis, or an infection caused by fusospirochetal or other anaerobic organisms.