Chapter 20 Assessment of respiratory
What is the purpose of the vascular and ciliated mucous lining of the nasal cavities? Cool and dry expired air Move mucus to the back of the throat 463 and humidify inspired air Moisten and filter expired air
463 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.
High or increased compliance occurs in which disease process? Emphysema Pneumothorax Pleural effusion ARDS
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).
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? Magnetic resonance imaging (MRI) Fluoroscopy Computed tomography (CT) scan Chest x-ray
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.
The nursing instructor is teaching students about the respiratory system. The instructor knows the teaching has been effective when a student makes which statement? "Ventilation is the exchange of gases in the lung." "Ventilation is the movement of air in and out of the respiratory tract." "Ventilation is the process of getting oxygen to the cells." "Ventilation is the process of gas exchange."
"Ventilation is the movement of air in and out of the respiratory tract." Explanation: Ventilation is the part of the respiration process that involves physical movement of air in and out of the respiratory tract. Respiration, not ventilation, encompasses the entire process of exchange of oxygen and CO2 between atmospheric air and the blood and between the blood and the cells.
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? Raised temperature in the affected limb Flushed feeling in the client Excessive capillary refill Absent distal pulses
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.
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? An infection with pneumococcal pneumonia Bronchitis A lung abscess Bronchiectasis
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 inspects the thorax of a patient with advanced emphysema. The nurse expects chest configuration changes consistent with a deformity known as: Funnel chest Barrel chest Pigeon chest Kyphoscoliosis
Barrel Chest
The nurse notes that a client has several normal breaths that are followed by apnea that varies in length. The nurse knows that this breathing pattern is also known as? Biot respirations Obstructive Hyperpnea Cheyne-Stokes
Biot respirations Explanation: Biot respirations are characterized by periods of normal breathing followed by varying periods of apnea. This breathing pattern is also called ataxic breathing and is associated with a drug overdose or brain injury at the level of the medulla. Hyperpnea is another term for hyperventilation. Obstructive breathing pattern has a prolonged expiratory phase and is associated with asthma, chronic obstructive pulmonary disease, and bronchitis. Cheyne-Stokes respirations are characterized by a regular cycle where the rate and depth of breathing increase and then decrease until an apnea period occurs.
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? Pleural rub Wheezes Rhonchi Crackles
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 enters the room of a client who is being monitored with pulse oximetry. Which of the following factors may alter the oximetry results? Reduced lighting in the room Placement of the probe on an earlobe Increased temperature of the room Diagnosis of peripheral vascular disease
Diagnosis of peripheral vascular disease Explanation: Pulse oximetry is a noninvasive method of monitoring oxygen saturation of hemoglobin. A probe is placed on the fingertip, forehead, earlobe, or bridge of nose. Inaccuracy of results may be from anemia, bright lights, shivering, nail polish, or peripheral vascular disease.
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 Absent distal pulses Hematoma Urge to cough
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.
Upon palpation of the sinus area, what would the nurse identify as a normal finding? Tenderness during palpation No tenderness during palpation Light not going through the sinus cavity Pain sensation behind the eyes
No tenderness 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 nurse practitioner diagnosed a patient with an infection in the maxillary sinuses. Select the area that the nurse palpated to make that diagnosis. Above the eyebrows Behind the ethmoid sinuses On the cheeks below the eyes Between the eyes and behind the nose
On the cheeks below the eyes Explanation: To palpate the maxillary sinuses, the nurse should apply gentle pressure in the cheek area below the eyes, adjacent to the nose.
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? Atelectasis Infective process Tumor Pulmonary embolism
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.
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? Rales Bronchovesicular Venous hum Rhonchi
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.
The nurse is admitting a client who just had a bronchoscopy. Which assessment should be the nurse's priority? Swallow reflex Ability to deep breathe Medication allergies Presence of carotid pulse
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 documents breath sounds that are soft, with inspiratory sounds longer than expiratory and found over the periphery of the lungs. Which of the following will the nurse chart? Adventitious Tracheal Vesicular Bronchial
Vesicular Explanation: Vesicular breath sounds are heard over the entire lung field except the upper sternum and between the scapulae. Their pitch and intensity are low. Inspiration sounds are longer than expiratory sounds. These are considered normal breath sounds.
A client has recently been diagnosed with malignant lung cancer. The nurse is calculating the client's smoking history in pack-years. The client reports smoking two packs of cigarettes a day for the past 11 years. The nurse correctly documents the client's pack-years as 22. 11. 5. 10.
22 Explanation: Smoking history is usually expressed in pack-years, which is the number of packs of cigarettes smoked per day times the number of years the patient smoked. In this situation, the client's pack-years is 22 (2 × 11). It is important to find out whether the client is still smoking or when the client quit smoking.
A nurse would question the accuracy of a pulse oximetry evaluation in which of the following conditions? A client sitting in a chair after prolonged bed rest A client on a ventilator with PEEP A client experiencing hypothermia A client receiving oxygen therapy via Venturi mask
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.
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? Avoid atropines as they dry the secretions. Practice holding the breath for short periods. Avoid sedatives or narcotics as they depress the vagus nerve. Abstain from food for at least 6 hours before the procedure.
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.
The nurse is assessing the lungs of a patient diagnosed with pulmonary edema. Which of the following would be expected upon auscultation? Crackles at lung bases Absent breath sounds Bronchial breath sounds Egophony
Crackles at lung bases Explanation: A patient with pulmonary edema would be expected to have crackles in the lung bases, and possible wheezes. Egophony may occur in patients diagnosed with pleural effusion. Absent breath sounds occurs in pneumothorax. Bronchial breath sounds occur in consolidation, such as pneumonia.
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? Cyanosis Restlessness Dyspnea Confusion
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 nurse is concerned that a client may develop postoperative atelectasis. Which nursing diagnosis would be most appropriate if this complication occurs? Impaired spontaneous ventilation Impaired gas exchange Ineffective airway clearance Decreased cardiac output
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? Inflammation Cancer Infection Heart failure
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.
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? Respiratory rate is 12 to 18 breaths per minute. Client reports no chest pain. Lungs are clear on auscultation. Client can perform incentive spirometry.
Lungs are clear on auscultation
A physician has ordered that a client with suspected lung cancer undergo magnetic resonance imaging (MRI). The nurse explains the benefits of this study to the client. What is the reason the client with suspected lung cancer would undergo magnetic resonance imaging (MRI)? Lung blood flow can be viewed after a radiopaque agent is injected. MRI can view soft tissues and can help stage cancers. Narrow-beam x-ray can scan successive lung layers. Tumor densities can be seen with radiolucent images.
MRI can view soft tissues and can help stage cancers. Explanation: MRI uses magnetic fields and radiofrequency signals to produce a detailed diagnostic image. MRI can visualize soft tissues, characterize nodules, and help stage carcinomas. The other options describe different studies.
When assessing a client, which adaptation indicates the presence of respiratory distress? Sore throat Orthopnea Productive cough Respiratory rate of 14 breaths per minute
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.
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? SaO2 PaCO2 pH PaO2
PaCO2 Explanation: When the minute ventilation falls, alveolar ventilation in the lungs also decreases, and the PaCO2 increases.
A patient describes his chest pain as knife-like on inspiration. Which of the following is the most likely diagnosis? A lung infection Pleurisy Bronchogenic carcinoma Bacterial pneumonia
Pleurisy Explanation: Pleuritic pain from irritation of the parietal pleura is sharp and seems to "catch" on inspiration. Some patients describe the pain as being "stabbed by a knife." Chest pain associated with the other conditions may be dull, aching, and persistent.
What is the primary function of the larynx? Preventing infection Protecting the lower airway from foreign objects Facilitating coughing Producing sound
Producing sound Explanation: The larynx, or voice box, is a cartilaginous framework between the pharynx and trachea. Its primary function is to produce sound. While the larynx assists in protecting the lower airway, this is mainly the function of the epiglottis. Facilitating coughing is a secondary function of the larynx. Preventing infection is the main function of the tonsils and adenoids.
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 the nurse perform first? Arterial blood gases Pulse oximetry Chest x-ray Pulmonary function test
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 arrives at the physician's office stating 2 days of febrile illness, dyspnea, and cough. Upon assisting the client into a gown, the nurse notes that the client's sternum is depressed, especially on inspiration. Crackles are noted in the bases of the lung fields. Based on inspection, which will the nurse document? The client has pneumonia in the bases. The client has a funnel chest. The client needs a cough suppressant. The client has chronic respiratory disease.
The client has a funnel chest. Explanation: The question asks for a documentation based on inspection. A funnel chest, known as pectus excavatum, has the sternum depressed from the second intercostal space, and it is more pronounced on inspiration. The nurse would not diagnose chronic respiratory disease or pneumonia. The client would also not prescribe a cough suppressant.
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 are heard in clients with decreased secretions. They can be heard during inspiration and expiration. They result from air passing through widened air passages. They occur when the pleural surfaces are inflamed.
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 assesses a client's respiratory status. Which observation indicates that the client is having difficulty breathing? Diaphragmatic breathing Use of accessory muscles Pursed-lip breathing Controlled 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.
The nurse auscultates the lung sounds of a client during a routine assessment. The sounds produced are harsh and cracking, sounding like two pieces of leather being rubbed together. The nurse would be correct in documenting this finding as crackles. pleural friction rub. sonorous wheezes. sibilant wheezes.
pleural friction rub. Explanation: A pleural friction rub is heard secondary to inflammation and loss of lubricating pleural fluid. Crackles are soft, high-pitched, discontinuous popping sounds that occur during inspiration. Sonorous wheezes are deep, low-pitched rumbling sounds heard primarily during expiration. Sibilant wheezes are continuous, musical, high-pitched, whistle-like sounds heard during inspiration and expiration.
Pink, frothy sputum may be an indication of an infection. bronchiectasis. pulmonary edema. a lung abscess.
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.
In relation to the structure of the larynx, the cricoid cartilage is the valve flap of cartilage that covers the opening to the larynx during swallowing. used with the thyroid cartilage in vocal cord movement. the largest of the cartilage structures. the only complete cartilaginous ring in the larynx.
the only complete cartilaginous ring in the larynx. Explanation: The cricoid cartilage is 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 and 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.
The amount of air inspired and expired with each breath is called: residual volume. vital capacity. tidal volume. dead-space volume.
tidal volume. Explanation: Tidal volume is the amount of air inspired and expired with each breath. Residual volume is the amount of air remaining in the lungs after forcibly exhaling. Vital capacity is the maximum amount of air that can be moved out of the lungs after maximal inspiration and expiration. Dead-space volume is the amount of air remaining in the upper airways that never reaches the alveoli. In pathologic conditions, dead space may also exist in the lower airways.
Which hollow tube transports air from the laryngeal pharynx to the bronchi? bronchioles larynx trachea pharynx
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.
You are caring for a client admitted with chronic bronchitis. The client is having difficulty breathing, and the family asks you what causes this difficulty. What would be your best response? "Anytime there is a chronic disease process it is hard for the person to breathe." "Having a chronic respiratory disease scars the lung and affects the effort it takes to breathe." "In this particular case your family member is just overly tired and having problems breathing." "Conditions such as chronic bronchitis cause thickening of the bronchial mucosa so it makes it harder to breathe."
"Conditions such as chronic bronchitis cause thickening of the bronchial mucosa so it makes it harder to breathe." Explanation: Conditions that may alter bronchial diameter and affect airway resistance include contraction of bronchial smooth muscle (e.g., asthma); thickening of bronchial mucosa (e.g., chronic bronchitis); airway obstruction by mucus, a tumor, or a foreign body; and loss of lung elasticity (e.g., emphysema). Option A is incorrect, not all chronic diseases make it hard to breathe. Option B is incorrect; not all chronic respiratory diseases caused scarring in the lung. Option C is incorrect; this response negates the families question and belittles their concern.
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? Rubs Crackles Sibilant wheezes Sonorous wheezes
A decrease in airway diameter, such as in asthma, produces breath sounds of wheezes. Wheezes may be sibilant (hissing or whistling) or sonorous (full and deep). Sibilant wheezes (formerly called 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. Sonorous wheezes (formerly called rhonchi) are lower pitched and are heard in the trachea and bronchi. Sonorous wheezes are coarse, rattling sounds similar to snoring usually caused by secretion in the bronchial tree. Crackles, also called rales, are crackling or rattling sounds signifying fluid or exudate in the lung fields. Rubs are secretions that can be heard in the large airway.
The nurse is caring for a client who is in respiratory distress. The physician orders arterial blood gases (ABGs) to determine various factors related to blood oxygenation. What site can ABGs be obtained from? The pleural surfaces A catheter in the arm vein A puncture at the radial artery The trachea and bronchi
A puncture at the radial artery Explanation: ABGs determine the blood's pH, oxygen-carrying capacity, levels of oxygen, CO2, and bicarbonate ion. Blood gas samples are obtained through an arterial puncture at the radial, brachial, or femoral artery. A client also may have an indwelling arterial catheter from which arterial samples are obtained. Blood gas samples are not obtained from the pleural surfaces or trachea and bronchi.
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? Call dietary services to send the client's tray now. Assess for a cough reflex. Assess for bowel sounds. Perform mouth care.
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 is caring for a client with recurrent hemoptysis who has undergone a bronchoscopy. Immediately following the procedure, the nurse should complete which action? Assess the client for a cough reflex. Offer the client ice chips. Ensure the client remains moderately sedated to decrease anxiety. Instruct the client that bed rest must be maintained for 2 hours.
Assess the client for a cough 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.
A client appears to be breathing faster than during the last assessment. Which of the following actions should the nurse perform? Count the rate of respirations. Inquire if there have been any stressful visitors. Assess the radial pulse. Assist the client to lie down.
Count the rate of respirations. Explanation: Observing the rate and depth of respiration is an important aspect of a nursing assessment. The normal adult resting respiratory rate is 12 to 18 breaths per minute. Tachypnea is rapid breathing with a rate greater than 24 breaths per minute. An increase in the rate of respirations needs further investigation and must be reported.
Which is an age-related change associated with the respiratory system? Decreased size of the airway Increased chest muscle mass Increased elasticity of alveolar sacs Thinning of alveolar membranes
Decreased size of the airway Explanation: Age-related changes that occur in the respiratory system are a decrease in the size of the airway, decreased chest muscle mass, increased thickening of the alveolar membranes, and decreased elasticity of the alveolar sacs.
A nurse is preparing a client for bronchoscopy. Which instruction should the nurse give to the client? Do not eat or drink for 6 hours before the procedure. Do not cough after the procedure until you are walking. Do not talk for 2 hours before the procedure. Do not walk after the procedure for 4 to 6 hours.
Do not eat or drink for 6 hours before the procedure. Explanation: Bronchoscopy involves visualization of the trachea and bronchial tree. To prevent aspiration of stomach contents into the lungs, the nurse should instruct the client not to eat or drink anything for approximately 6 hours before the procedure. It isn't necessary for the client to avoid walking, talking, or coughing.
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? Tympanic Hyperresonant Resonant Dull
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.
The nurse is taking a respiratory history for a patient who has come into the clinic with a chronic cough. What information should the nurse obtain from this patient? (Select all that apply). Previous history of lung disease Financial Ability Previous history of smoking Social Support Occupational and environmental influences
Previous history of lung disease Occupational and environmental influences Previous history of smoking Explanation: Risk factors associated with respiratory disease include smoking, exposure to allergens and environmental pollutants, and exposure to certain recreational and occupational hazards. Financial stability and social support are not pertinent to a chronic cough.
A nurse is discussing squamous epithelial cells lining each alveolus, which consist of different types of cells. Which type of alveolar cells produce surfactant? Type III cells Type II cells Type IV cells Type I cells
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 caring for a patient with a pulmonary embolism understands that a high ventilation-perfusion ratio may exist. What does this mean for the patient? There is an absence of perfusion and ventilation. Ventilation matches perfusion. Perfusion exceeds ventilation. Ventilation exceeds perfusion.
Ventilation exceeds perfusion. Explanation: A high ventilation-perfusion rate means that ventilation exceeds perfusion, causing dead space. The alveoli do not have an adequate blood supply for gas exchange to occur. This is characteristic of a variety of disorders, including pulmonary emboli, pulmonary infarction, and cardiogenic shock.
The nurse is caring for a client diagnosed with pneumonia. The nurse assesses the client for tactile fremitus by completing which action? Asking the client to say "one, two, three" while the nurse auscultates the lungs Placing the thumbs along the costal margin of the chest wall and instructing the client to inhale deeply Asking the client to repeat "ninety-nine" as the nurse's hands move down the client's thorax Instructing the client to take a deep breath and hold it while the diaphragm is percussed
Asking the client to repeat "ninety-nine" as the nurse's hands move down the client's thorax Explanation: While the nurse is assessing for tactile fremitus, the client is asked to repeat "ninety-nine" or "one, two, three," or "eee, eee, eee" as the nurse's hands move down the client's thorax. Vibrations are detected with the palmar surfaces of the fingers and hands, or the ulnar aspect of the extended hands, on the thorax. The hand(s) are moved in sequence down the thorax, and corresponding areas of the thorax are compared. Asking the client to say "one, two, three" while auscultating the lungs is not the proper technique to assess for tactile fremitus. The nurse assesses for anterior respiratory excursion by placing the thumbs along the costal margin of the chest wall and instructing the client to inhale deeply. The nurse assesses for diaphragmatic excursion by instructing the client to take a deep breath and hold it while the diaphragm is percussed.
A patient with sinus congestion points to a location on the inside of his eye as the area of pain. The nurse documents that the patient is complaining of pain in which sinus? Sphenoid Frontal Maxillary Ethmoid
Ethmoid Explanation: The ethmoidal sinuses are located between the eyes and behind the nose. Inflammation and swelling block drainage into the nose; eventually an infection results.
A client is seen in the emergency room for a case of diabetic acidosis with the presence of Kussmaul respirations. What client condition is associated with the presence of Kussmaul respirations? Bradypnea Tachypnea Hypoventilation Hyperventilation
Hyperventilation Explanation: Hyperventilation is an increased rate and depth of breathing that results in decreased PaCO2 levels and inspiration and expiration nearly equal in duration This is associated with exertion, anxiety, and metabolic acidosis. This hyperventilation is called Kussmaul respiration if associated with diabetic ketoacidosis or renal origin. Bradypnea is breaths slower than 10 per minute. Tachypnea is rapid, shallow breathing exceeding 24 breaths per minute. Hypoventilation is shallow, irregular breathing.
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: nail beds. lips. earlobes. mucous membranes.
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 reviews the results of a client's ventilation-perfusion (V/Q) scan. For which condition will the nurse plan care when the ventilation-perfusion ratio is less than 0.80? Pneumonia Pulmonary infarction Cardiogenic shock Pulmonary emboli
Pneumonia Explanation: Adequate gas exchange depends on an adequate ventilation-perfusion (V̇/Q̇) ratio. In different areas of the lung, the (V̇/Q̇) ratio varies. V̇/Q̇ imbalance occurs as a result of inadequate ventilation, inadequate perfusion, or both. Low ventilation-perfusion states may be called shunt-producing disorders. When perfusion exceeds ventilation, a shunt exists . Blood bypasses the alveoli without gas exchange occurring. This is seen with obstruction of the distal airways, such as with pneumonia, atelectasis, tumor, or a mucus plug. In the absence of both ventilation and perfusion or with limited ventilation and perfusion, a condition known as a silent unit occurs. This is seen with pneumothorax and severe acute respiratory distress syndrome. When ventilation exceeds perfusion, dead space results. The alveoli do not have an adequate blood supply for gas exchange to occur. This is characteristic of a variety of disorders, including pulmonary emboli, pulmonary infarction, and cardiogenic shock.
A client has been newly diagnosed with emphysema. The nurse should explain to the client that by definition, ventilation: helps people who cannot breathe on their own. is when the body changes oxygen into CO2. provides a blood supply to the lungs. is breathing air in and out of the lungs.
is breathing air in and out of the lungs. Explanation: Ventilation is the actual movement of air in and out of the respiratory tract. Diffusion is the exchange of oxygen and CO2 through the alveolar-capillary membrane. Pulmonary perfusion refers to the provision of blood supply to the lungs. A mechanical ventilator assists patients who are unable to breathe on their own.
Which is a true statement regarding air pressure variances? The diaphragm relaxes during inspiration. Air is drawn through the trachea and bronchi into the alveoli during inspiration. The thoracic cavity becomes smaller during inspiration. Air flows from a region of lower pressure to a region of higher pressure during inspiration.
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.
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: Posterior surface of the left side of the chest, near the sixth rib. Posterior surface of the right side of the chest, near T3. Anterior surface of the left side of the chest, near the sixth rib. Anterior surface of the right side of the chest, between the fourth and fifth rib.
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.
A client presents to the emergency department with fluid overload. The nurse is concerned about fluid accumulation in the lungs. On which of the following areas would the nurse focus the lung assessment? Posterior bronchioles Right lower lobe Bilateral lower lobes Anterior bronchial tree
Bilateral lower lobes Explanation: Assessment of the anterior and posterior lungs is part of the nurse's routine evaluation. Fluid overload should be monitored for accumulation in the lungs. Dependent areas must be assessed for breath sounds. The bases of the lungs are considered dependent areas. Fluid in the lungs will usually produce the adventitious sounds of crackles, most frequently auscultated in the bilateral bases of the lungs.
What finding by the nurse may indicate that the client has chronic hypoxia? Clubbing of the fingers Peripheral edema Crackles Cyanosis
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.
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. Anteroposterior rib diameter decreases. Lungs are pulled up and pushed back against the thoracic cage. Diaphragm contracts and elongates the chest cavity. Intercostals muscles relax to allow for expansion.
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.
The nurse knows that what condition is associated with increased compliance of the lungs? Pleural effusion Atelectasis Emphysema Pulmonary edema
Emphysema Explanation: Compliance is normal if the lungs and the thorax easily stretch and distend. Increased compliance occurs if the lungs have lost their elastic recoil and become overdistended as in emphysema. Decreased compliance occurs if the lungs and the thorax are "stiff." Conditions associated with decreased compliance include morbid obesity, pneumothorax, hemothorax, pleural effusion, pulmonary edema, atelectasis, pulmonary fibrosis, and acute respiratory distress syndrome (ARDS). This causes airway collapse during expiration, dyspnea, and eventually cyanosis.
While assessing for tactile fremitus, the nurse palpates almost no vibration. Which of the following conditions in this client's history will account for this finding? Pigeon chest Emphysema Pneumonia Funnel chest
Emphysema Explanation: Tactile fremitus is assessed through vibrations of sound on the chest wall by palpation. Normally, fremitus is felt most over the large bronchi and least over the distant lung fields. Clients with emphysema exhibit almost no fremitus, because of the rupture of alveoli and the trapping of air. Air does not conduct sound well
A client with sinus congestion complains of discomfort when the nurse is palpating the supraorbital ridges. What sinus is the client referring? Sphenoidal Maxillary Ethmoidal Frontal
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.
A patient diagnosed with diabetic ketoacidosis would be expected to have which type of respiratory pattern? Apnea Kussmaul respirations Cheyne-Stokes Biot's respirations
Kussmaul respirations Explanation: Kussmaul respirations are seen in patients with diabetic ketoacidosis. In Cheyne-Stokes respiration, rate and depth increase, then decrease until apnea occurs. Biot's respiration is characterized by periods of normal breathing (3 to 4 breaths) followed by a varying period of apnea (usually 10 to 60 seconds).
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? Sibilant wheezes Crackles Sonorous wheezes Rubs
Sibilant wheezes Explanation: A decrease in airway diameter, such as in asthma, produces breath sounds of wheezes. Wheezes may be sibilant (hissing or whistling) or sonorous (full and deep). Sibilant wheezes (formerly called 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. Sonorous wheezes (formerly called rhonchi) are lower pitched and are heard in the trachea and bronchi. Sonorous wheezes are coarse, rattling sounds similar to snoring usually caused by secretion in the bronchial tree. Crackles, also called rales, are crackling or rattling sounds signifying fluid or exudate in the lung fields. Rubs are secretions that can be heard in the large airway.
An client is described as having pectus carinatum. What would be the physical manifestation of this condition? The sternum is depressed from the second intercostal space. The sternum protrudes and the ribs are sloped backward. The thoracic and lumbar spine have a lateral S-shaped curvature. The chest is rounded, ribs are horizontal, and sternum is pulled forward.
The sternum protrudes and the ribs are sloped backward. Explanation: Also known as pigeon chest, in this congenital anomaly, the sternum abnormally protrudes and the ribs are sloped backward. A depressed sternum would be considered funnel chest, or pectus excavatum. S-shaped spinal curvature would be considered scoliosis. A rounded chest would be considered barrel chest in which the anteroposterior diameter increases to equal the transverse diameter.
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? Wheezes Rhonchi Crackles Rales
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 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. raise the arm on the side of the client's body on which the physician will perform the thoracentesis. place the client supine in the bed, which is flat. raise the head of the bed to a high Fowler's position.
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.
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? "I will feel light-headed when the contrast medium is introduced." "I will feel waves of nausea throughout the procedure." "I will feel warm and may have chest pain" "I will feel a dull pain when the catheter is introduced."
"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.
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? "My study is scheduled for 10 AM, several hours after I eat." "I am ordered a bronchodilator to note lung improvement following use." "I will breathe in through my mouth and out through my nose." "I brought comfortable clothes and shoes for the test."
"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 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? 40% 95% 75% 80%
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 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? Pneumothorax Acute respiratory obstruction Adult respiratory distress syndrome Asthma
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.
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? Son's statement Cyanosis Crackles Respiratory rate
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.
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 less than anteroposterior diameter Anteroposterior diameter that equals the lateral diameter Elevation of the scapula with the lateral diameter unaffected Lateral diameter greater than anteroposterior diameter
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.
A young adult visited a clinic because he was injured during a softball game. He told the nurse that the ball struck him in his "Adam's apple." To assess the initial impact of injury, the nurse: Inspects the epiglottis. Inspects the vocal cords. Palpates the cricoid cartilage. Palpates the thyroid cartilage.
Palpates the thyroid cartilage. Explanation: The term "Adam's Apple" is used to refer to a lump or protrusion, a laryngeal prominence. It is formed by the angle of the thyroid cartilage surrounding the larynx.
Which of the following is a noninvasive method of continuously monitoring the oxygen saturation of hemoglobin (SaO2)? Sputum studies Pulse oximetry Pulmonary function testing Arterial blood gas analysis
Pulse oximetry Explanation: Pulse oximetry is a noninvasive method of continuously monitoring SaO2. Measurements of blood pH of arterial oxygen and carbon dioxide tensions are obtained when managing patients with respiratory problems and adjusting oxygen therapy as needed. This is an invasive procedure. Pulmonary function testing assesses respiratory function and determines the extent of dysfunction. Sputum studies are done to identify if any pathogenic organisms or malignant cells are in the sputum.
Which of the following ventilation-perfusion mismatch would correlate with acute respiratory distress syndrome (ARDS)? Normal Shunt Silent unit Dead space
Silent unit Explanation: A silent unit (a combination of shunting and dead-space ventilation) occurs when little or no ventilation and perfusion is present, such as in ARDS. A dead space, which is reduced perfusion to a lung unit, occurs in pulmonary embolism. Shunting, reduced ventilation to a lung unit, occurs in pneumonia and atelectasis. Patients with ARDS do not have a normal V/Q [adV]/[adQ]) match.
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? Prone Lateral recumbent Sitting on the edge of the bed Supine
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. Tickle the back of the throat to produce the gag reflex. Drink 8 oz of water to thin the secretions for expectoration. Use the secretions present in the oral cavity.
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.
A client arrives at the physician's office stating 2 days of febrile illness, dyspnea, and cough. Upon assisting the client into a gown, the nurse notes that the client's sternum is depressed, especially on inspiration. Crackles are noted in the bases of the lung fields. Based on inspection, which will the nurse document? The client needs a cough suppressant. The client has pneumonia in the bases. The client has a funnel chest. The client has chronic respiratory disease.
The client has a funnel chest. Explanation: The question asks for a documentation based on inspection. A funnel chest, known as pectus excavatum, has the sternum depressed from the second intercostal space, and it is more pronounced on inspiration. The nurse would not diagnose chronic respiratory disease or pneumonia. The client would also not prescribe a cough suppressant.
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 asking a question requiring a verbal response. The nursing assistant is assisting the client to the side of the bed to use a urinal. The nursing assistant is assisting the client to a semi-Fowler's position. The nursing assistant is pouring a glass of water to wet the client's mouth.
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.