Ch. 17: Assessment of Respiratory Function

The student nurse is caring for a client who has serial sputum tests ordered. The student asks the instructor why the sputum tests have to be repeated on successive days. What would be the instructor's best response?

"A negative sputum test does not always mean that there is no disease present, so more than one test may be needed." Explanation: Negative results on the examination of sputum smears do not always indicate the absence of disease, so collection of sputum for successive days may be necessary. This makes options A, B, and C incorrect.

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?

95% Explanation: Normal SpO2 values are more than 95%. Values less than 90% indicate that the tissues are not receiving enough oxygen, in which case further evaluation is needed.

The nurse is performing a respiratory assessment of a client who has been experiencing episodes of hypoxia. The nurse is aware that this example of impaired gas exchange is primarily dependent upon what?

An inadequate ventilation-perfusion ratio Explanation: Adequate gas exchange depends on an adequate ventilation-perfusion ratio. There is no perfusion-diffusion ratio. Adequate gas exchange does not depend on the diffusion of gas in shunted blood or a particular concentration of nitrogen.

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?

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 auscultated a patient's middle lobe of the lungs for abnormal breath sounds. To do this, the nurse placed the stethoscope on the:

Anterior surface of the right side of the chest, between the fourth and fifth rib. Explanation: The middle lobe of the lung is only found on the right side of the thorax and can only be assessed anteriorly. It is located at the fourth rib, at the right sternal border and extends to the fifth rib, in the midaxillary line.

The nurse has assessed a client's family history for three generations. The presence of which respiratory disease would justify this type of assessment?

Asthma Explanation: Asthma is a respiratory illness that has genetic factors. Sleep apnea, pneumonia, and pulmonary edema lack genetic risk factors.

The nurse is performing an assessment of a patient who arrived in the emergency department with a barbiturate overdose. The respirations are normal for 3 to 4 breaths followed by a 60-second period of apnea. How does the nurse document the respirations?

Biot's respirations Explanation: Biot's respirations are characterized by periods of normal breathing (3-4 breaths) followed by a varying period of apnea (usually 10-60 s). They are associated with respiratory depression resulting from drug overdose and brain injury, normally at the level of the medulla. Cheyne-Stokes respirations are characterized by a regular cycle in which the rate and depth of breathing increase and then decrease until apnea (usually about 20 s) occurs. The duration of apnea may vary and progressively lengthen; therefore, it is timed and reported. Tachypnea is rapid, shallow breathing (>24 breaths/min). Bradypnea is breathing at a slower-than-normal rate (<10 breaths/min), with normal depth and regular rhythm.

What finding by the nurse may indicate that the client has chronic hypoxia?

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.

The nurse is caring for an older client in the PACU. The client has had a bronchoscopy, and the nurse is monitoring for complications related to the administration of topical lidocaine. For what complication related to the administration of large doses of topical lidocaine in older adults should the nurse assess?

Confusion and lethargy Explanation: Lidocaine may be sprayed on the pharynx or dropped on the epiglottis and vocal cords and into the trachea to suppress the cough reflex and minimize discomfort during a bronchoscopy. After the procedure, the nurse will assess for confusion and lethargy in an older adult, which may be due to the large doses of lidocaine given during the procedure. The other listed signs and symptoms are not specific to this problem.

A client diagnosed with heart failure has not yet responded to treatment. What breath sound should the nurse expect to assess on auscultation?

Crackles Explanation: Crackles reflect underlying inflammation or congestion and are often present in such conditions as pneumonia, bronchitis, and congestive heart failure. Rhonchi and wheezes are associated with airway obstruction, which is not a part of the pathophysiology of heart failure.

Which ventilation-perfusion ratio is exhibited in a client diagnosed with a pulmonary embolus?

Dead space Explanation: A dead space exists when ventilation exceeds perfusion (high ventilation-perfusion ratios). An example of a dead space is a pulmonary embolus, pulmonary infarction, and cardiogenic shock. A low ventilation-perfusion ratio exists in pneumonia or with a mucus plug. A silent unit occurs in pneumothorax or acute respiratory distress syndrome.

The nurse working on a gerontology unit admits a 77-year-old with recent shortness of breath. The nurse knows that the amount of respiratory dead space increases with age. What do these changes result in?

Decreased diffusion capacity for oxygen Explanation: The amount of respiratory dead space increases with age. These changes result in a decreased diffusion capacity for oxygen with increasing age, producing lower oxygen levels in the arterial circulation. Shunting does not typically decrease and ventilation does not increase.

A nurse is caring for an older adult with pneumonia. What are age-related structural and functional changes that occur in the respiratory system? Select all that apply.

Decreased elasticity of the alveolar sacs Increased residual volume Increased diameter of alveolar ducts Increased thickness of alveolar sacs Explanation: Decreased elasticity of the alveolar sacs, increased residual volume, increased diameter of alveolar ducts, and increased thickness of alveolar sacs are age-related changes in the respiratory system. Pulmonary compliance increases with aging. Dead space increases with aging.

Which of the following clinical manifestations should a nurse monitor for during a pulmonary angiography, which indicates an allergic reaction to the contrast medium?

Difficulty in breathing Explanation: Nurses must determine if the client has any allergies, particularly to iodine, shellfish, or contrast dye. During the procedure, the nurse should check for signs and symptoms of allergic reactions to the contrast medium, such as itching, hives, or difficulty in breathing. The nurses inspects for hematoma, absent distal pulses, after the procedure. When the contrast medium is infused, an urge to cough is often a sensation experienced by the client.

High or increased compliance occurs in which condition?

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).

High or increased compliance occurs in which disease process?

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 pulmonary assessment, the nurse observes the chest for configuration. She identifies the findings as normal. Which of the following would be consistent with normal assessment?

Lateral diameter greater than anteroposterior diameter Explanation: Inspecting the thorax is part of assessment of the respiratory system. Normally, the ratio of the anteroposterior diameter to the lateral diameter is 1:2. Chest deformities are associated with respiratory disease.

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?

PaCO2 Explanation: When the minute ventilation falls, alveolar ventilation in the lungs also decreases, and the PaCO2 increases.

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?

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.

An 18-month-old child is brought to the Emergency Department by parents who explain that their child swallowed a watch battery. Radiologic studies show that the battery is in the lungs. Which area of lung is the battery most likely to be in?

Right upper lung Explanation: Aspiration of foreign objects is more likely in the right mainstem bronchus and right upper lung.

The nurse is caring for a client who is to undergo a thoracentesis. In preparation for the procedure, the nurse places the client in which position?

Sitting on the edge of the bed Explanation: If possible, it is best to 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 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 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?

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.

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?

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.

A nurse assesses a client's respiratory status. Which observation indicates that the client is having difficulty breathing?

Use of accessory muscles Explanation: The use of accessory muscles for respiration indicates the client is having difficulty breathing. Diaphragmatic and pursed-lip breathing are two controlled breathing techniques that help the client conserve energy.

A client seeks medical attention for new-onset cough and sputum production. The client is producing sputum that is yellowish-green in color and thick in consistency. The nurse anticipates which action for these types of symptoms?

increased hydration Explanation: Cough results from irritation or inflammation of the mucous membranes anywhere in the respiratory tract and is associated with multiple pulmonary disorders. Of the choices provided, the nurse would anticipate that increased hydration would be recommended for this client. Cough suppressants should be used with caution as they do not address the etiology of the cough. CT scans are used to distinguish fine-tissue density and are used to help diagnose pulmonary embolism. This client is not experiencing symptoms of a pulmonary embolism. Prone positioning is used for clients experiencing acute respiratory distress syndrome (ARDS), not a cough with sputum production.

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:

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.

The nurse is caring for a client who is scheduled for a bronchoscopy. The nurse understands that it is important to provide the required information and appropriate explanations for any diagnostic procedure with a respiratory disorder in a way that:

reduces fear and decreases anxiety. Explanation: In addition to the nursing management of individual tests, clients with respiratory disorders require informative and appropriate explanations of any diagnostic procedures they will experience. The nurse should explain the procedure to the client in order to reduce fear and decrease anxiety. Nurses must remember that for many of these clients, breathing may in some way be compromised and energy levels may be decreased. For that reason, explanations should be brief, yet complete, and may need to be repeated later after a rest period. Providing information will not manage the client's respiratory distress. The education should be geared toward ensuring the client is aware of the procedure and not focused on aiding the caregivers.

The nurse is caring for a client who has just returned to the unit after a colon resection. The client is showing signs of hypoxia. The nurse knows that this is probably caused by:

shunting. Shunting appears to be the main cause of hypoxia after thoracic or abdominal surgery and most types of respiratory failure. Impairment of normal diffusion is a less common cause. Infection would not likely be present at this early stage of recovery and nitrogen narcosis only occurs from breathing compressed air.