Ch 21 PrepU questions

Which ventilation-perfusion ratio is exhibited by a pulmonary emboli?

Dead space Explanation: When ventilation exceeds perfusion a dead space exists. An example of a dead space is pulmonary emboli. A low ventilation-perfusion ratio exists in pneumonia or with a mucus plug. A silent unit occurs in pneumothorax or ARDS.

Which of the following is an age-related change associated with the lung?

Increased thickness of the alveolar membranes Explanation: Age-related changes associated with the lung include increased thickness of the alveolar membranes, decreased elasticity of alveolar air sacs, increased diameter of alveoli ducts, and increased collagen of alveolar membranes.

Why is it important for a nurse to provide required information and appropriate explanations of diagnostic procedures to patients with respiratory disorders?

Manage decreased energy levels Explanation: In addition to the nursing management of individual tests, patients with respiratory disorders require informative and appropriate explanations of any diagnostic procedures they will experience. Nurses must remember that for many of these patients, breathing may in some way be compromised. 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. The nurse must also ensure adequate rest periods before and after the procedures. After invasive procedures, the nurse must carefully assess for signs of respiratory distress.

When assessing a client, which adaptation indicates the presence of respiratory distress?

Orthopnea Explanation: Orthopnea is the inability to breathe easily except when upright. This positioning can mean while in bed and propped with a pillow or sitting in a chair. If a client cannot breathe easily while lying down, there is an element of respiratory distress.

Your client has just had an invasive procedure to assess the respiratory system. What do you know should be assessed on this client?

Respiratory distress Correct Explanation: After invasive procedures, the nurse must carefully check for signs of respiratory distress and blood-streaked sputum. Masses in the pleural space are a condition that affects fremitus. General examination of overall health and condition includes assessing the consciousness of a client.

The instructor of the pre-nursing physiology class is explaining respiration to the class. What does the instructor explain is the main function of respiration?

To exchange oxygen and CO2 between the atmospheric air and the blood and between the blood and the cells Explanation: The main function of the respiratory system is to exchange oxygen and CO2 between the atmospheric air and the blood and between the blood and the cells. This process is called respiration. The purpose of respiration is not to move any gas into the expired air; retained air is simply a distractor for this question; and atmospheric air is not exchanged between the blood and the cells.

Upon palpation of the sinus area, what would the nurse identify as a normal finding?

No sensation during palpation Explanation: Sinus assessment involves using the thumbs to apply gentle pressure in an upward fashion at the sinuses. Tenderness suggests inflammation. The sinuses can be inspected by transillumination, where a light is passed through the sinuses. If the light fails to penetrate, the cavity contains fluid.

A client with chronic bronchitis is admitted with an exacerbation of symptoms. During the nursing assessment, the nurse will expect which of the following findings? Select all that apply.

• Use of accessory muscles to breathe • Purulent sputum with frequent coughing Explanation: Chronic bronchitis increases airway resistance and can thicken bronchial mucosa during an exacerbation. The client will have dyspnea requiring the use of accessory muscles to breathe, along with tachypnea and sputum production. Bronchial irritation and the need to expectorate mucus will lead to coughing. Percussion in this client would lead to resonant or hyperresonant sounds.

Which assessment finding would be most consistent with advanced emphysema?

Barrel-shaped chest Correct Explanation: Barrel chest occurs as result of overinflation of the lungs. In a client with emphysema, the ribs are more widely spaced and the intercostal spaces tend to bulge on expiration. The apprearance of a such a client with advanced emphysema is easily detected.

The term for the volume of air inhaled and exhaled with each breath is

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.

A nurse would question the accuracy of a pulse oximetry evaluation in which of the following conditions?

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 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?

Assess for a cough reflex. Correct 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

Which of the following is a deformity of the chest that occurs as a result of over inflation of the lungs?

Barrel chest Explanation: A barrel chest occurs as a result of over inflation of the lungs. There is an increase in the anteroposterior diameter of the thorax. Funnel chest occurs when there is a depression in the lower portion of the sternum, which may result in murmurs. Pigeon chest occurs as a result of displacement of the sternum resulting in an increase in the anteroposterior diameter. Kyphoscoliosis is characterized by elevation of the scapula and a corresponding S-shaped spine. This deformity limits lung expansion within the thorax.

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?

Exploration and biopsy of the lymph nodes that drain the lungs Correct 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 concerned that a client may develop postoperative atelectasis. Which nursing diagnosis would be most appropriate if this complication occurs?

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.

n which position should the patient be placed for a thoracentesis?

Sitting on the edge of the bed Explanation: If possible place the patient 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 patient 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 unable to assume a sitting position.

Which of the following results in decreased gas exchange in older adults?

The alveolar walls contain fewer capillaries. Explanation: Although the number of alveoli remains stable with age, the alveolar walls become thinner and contain fewer capillaries, resulting in decreased gas exchange. The lungs also lose elasticity and become stiffer. Elasticity of lungs does not increase with age, and number of alveoli does not decrease with age.

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?

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.

Which of the following alveolar cells secrete surfactant?

Type II Explanation: Type II alveolar cells are metabolically active and secrete surfactant, a phospholipid that decrease the surface tension in the alveoli and prevents their collapse. Type I alveolar cells are epithelial cells that form the alveolar walls. Type III alveolar cell macrophages are large phagocytic cells that ingest foreign matter and act as an important defense mechanism. Type IV is not a category of alveolar cells.

The nursing instructor is teaching a pre-nursing pathophysiology class. The class is covering the respiratory system. The instructor explains that the respiratory system is comprised of both the upper and lower respiratory system. The nose is part of the upper respiratory system. The instructor continues to explain that the nasal cavities have a vascular and ciliated mucous lining. What is the purpose of the vascular and ciliated mucous lining of the nasal cavities?

Warm and humidify inspired air Correct 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.

A nurse is preparing a client with a pleural effusion for a thoracentesis. The nurse should:

assist the client to a sitting position on the edge of the bed, leaning over the bedside table. Explanation: A physician usually performs a thoracentesis when the client is sitting in a chair or on the edge of the bed, with the legs supported and the arms folded and resting on a pillow or on the bedside table. Raising an arm, lying supine, or raising the head of the bed won't allow the physician to easily access the thoracic cavity.

Pink frothy sputum may be an indication of

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.

You are the hospice nurse caring for a client with pulmonary fibrosis who wants to die at home. The client is having difficulty breathing. The family asks why it is so hard for the client to breathe. What would be the nurse's best response?

"The fibrosis of the lungs makes the lungs stiff, which makes it harder to breathe. Correct Explanation: Decreased surfactant, fibrosis, edema, and atelectasis (alveolar collapse) affect lung compliance. Greater pressure gradients are needed when lungs are stiff. Options A, B, and D are incorrect because the information given to the family is incorrect.

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?

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.

An 83-year-old client was originally admitted for surgery and has suffered multiple postoperative complications. The pulmonologist has scheduled a thoracentesis to obtain a sample of pleural fluid or a biopsy specimen from the pleural wall for diagnostic purposes. What does serous fluid indicate?

Inflammation Explanation: A thoracentesis may be performed to obtain a sample of pleural fluid or to biopsy a specimen from the pleural wall for diagnostic purposes. Serous fluid may be associated with cancer, inflammatory conditions, or heart failure.

The nursing instructor is talking with senior nursing students about diagnostic procedures used in respiratory diseases. The instructor discusses thoracentesis, defining it as a procedure performed for diagnostic purposes or to aspirate accumulated excess fluid or air from the pleural space. What would the instructor tell the students purulent fluid indicates?

nfection 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.