Chapter 20: Assessment of Respiratory Function

Normally, approximately what percentage of the blood pumped by the right ventricle does not perfuse the alveolar capillaries? A.) 2% B.) 4% C.) 6% D.) 8%

Answer: A.) 2%

Which assessment finding would be most consistent with advanced emphysema? A.) Dependent edema B.) Epigastric pain C.) Barrel-shaped chest D.) Aortic bruit

Answer: C.) Barrel-shaped chest

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? A.) Raised temperature in the affected limb B.) Excessive capillary refill C.) Absent distal pulses D.) Flushed feeling in the client

ANswer: C.) Absent distal pulses

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? A.) A puncture at the radial artery B.) The trachea and bronchi C.) The pleural surfaces D.) A catheter in the arm vein

Answer: A.) A puncture at the radial artery Rationale: 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.

The nurse is caring for a client diagnosed with pneumonia. The nurse assesses the client for tactile fremitus by completing which action? A.) Asking the client to repeat "ninety-nine" as the nurse's hands move down the client's thorax B.) Asking the client to say "one, two, three" while the nurse auscultates the lungs C.) Instructing the client to take a deep breath and hold it while the diaphragm is percussed D.) Placing the thumbs along the costal margin of the chest wall and instructing the client to inhale deeply

Answer: A.) Asking the client to repeat "ninety-nine" as the nurse's hands move down the client's thorax

The nurse is caring for an adolescent client injured in a snowboarding accident. The client has a head injury, a fractured right rib, and various abrasions and contusions. The client has a blood pressure of 142/88 mm Hg, pulse of 102 beats/minute, and respirations of 26 breaths/minute. Which laboratory test best provides data on a potential impairment in ventilation? A.) Blood gases B.) Complete blood count C.) Blood chemistry D.) Serum alkaline phosphate

Answer: A.) Blood gases

The nurse is assessing the lungs of a patient diagnosed with pulmonary edema. Which of the following would be expected upon auscultation? A.) Crackles at lung bases B.) Egophony C.) Absent breath sounds D.) Bronchial breath sounds

Answer: A.) Crackles at lung bases

Which of the following clinical manifestations should a nurse monitor for during a pulmonary angiography, which indicates an allergic reaction to the contrast medium? A.) Difficulty in breathing B.) Hematoma C.) Absent distal pulses D.) Urge to cough

Answer: A.) Difficulty in breathing

A patient diagnosed with diabetic ketoacidosis would be expected to have which type of respiratory pattern? A.) Kussmaul respirations B.) Cheyne-Stokes C.) Biot's respirations D.) Apnea

Answer: A.) Kussmaul respirations

What is the primary function of the larynx? A.) Producing sound B.) Protecting the lower airway from foreign objects C.) Facilitating coughing D.) Preventing infection

Answer: A.) Producing sound Rationale: 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.

In relation to the structure of the larynx, which describes the cricoid cartilage? A.) The only complete cartilaginous ring in the larynx B.) Used with the thyroid cartilage in vocal cord movement C.) The largest of the cartilage structures D.) The valve flap of cartilage that covers the opening to the larynx during swallowing

Answer: A.) The only complete cartilaginous ring in the larynx Rationale: 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? A.) The pons B.) The frontal lobe C.) Central sulcus D.) Wernicke's area

Answer: A.) The pons Rationale: 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.

Which hollow tube transports air from the laryngeal pharynx to the bronchi? A.) trachea B.) larynx C.) bronchioles D.) pharynx

Answer: A.) trachea Rationale: 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 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? A.) Respiratory rate B.) Cyanosis C.) Son's statement D.) Crackles

Answer: B.) Cyanosis

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? A.) Placement of the probe on an earlobe B.) Diagnosis of peripheral vascular disease C.) Reduced lighting in the room D.) Increased temperature of the room

Answer: B.) Diagnosis of peripheral vascular disease

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. A.) Lungs are pulled up and pushed back against the thoracic cage. B.) Diaphragm contracts and elongates the chest cavity. C.) Intercostals muscles relax to allow for expansion. D.) Anteroposterior rib diameter decreases.

Answer: B.) Diaphragm contracts and elongates the chest cavity. Rationale: 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 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? A.) Frontal B.) Ethmoid C.) Maxillary D.) Sphenoid

Answer: B.) Ethmoid Rationale: 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 nurse is concerned that a client may develop postoperative atelectasis. Which nursing diagnosis would be most appropriate if this complication occurs? A.) Ineffective airway clearance B.) Impaired gas exchange C.) Decreased cardiac output D.) Impaired spontaneous ventilation

Answer: B.) Impaired gas exchange Rationale: 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 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? A.) Client can perform incentive spirometry. B.) Lungs are clear on auscultation. C.) Respiratory rate is 12 to 18 breaths per minute. D.) Client reports no chest pain.

Answer: B.) Lungs are clear on auscultation. Rationale: 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 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? A.) Dyspnea B.) Orthopnea C.) Tachypnea D.) Bradypnea

Answer: B.) Orthopnea

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? A.) Prone B.) Sitting on the edge of the bed C.) Supine D.) Lateral recumbent

Answer: B.) Sitting on the edge of the bed Rationale: 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 is admitting a client who just had a bronchoscopy. Which assessment should be the nurse's priority? A.) Medication allergies B.) Swallow reflex C.) Presence of carotid pulse D.) Ability to deep breathe

Answer: B.) Swallow reflex Rationale: 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.

A nurse assesses a client's respiratory status. Which observation indicates that the client is having difficulty breathing? A.) Diaphragmatic breathing B.) Use of accessory muscles C.) Pursed-lip breathing D.) Controlled breathing

Answer: B.) Use of accessory muscles Rationale: 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.

What is the difference between respiration and ventilation? A.) Ventilation is the process of gas exchange. B.) Ventilation is the movement of air in and out of the respiratory tract. C.) Ventilation is the process of getting oxygen to the cells. D.) Ventilation is the exchange of gases in the lung.

Answer: B.) Ventilation is the movement of air in and out of the respiratory tract. Rationale: 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.

The volume of air inhaled and exhaled with each breath is termed A.) residual volume. B.) tidal volume. C.) vital capacity. D.) expiratory reserve volume.

Answer: B.) tidal volume. Rationale: 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 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? A.) Right lower lobe B.) Posterior bronchioles C.) Bilateral lower lobes D.) Anterior bronchial tree

Answer: C.) Bilateral lower lobes

What finding by the nurse may indicate that the client has chronic hypoxia? A.) Crackles B.) Peripheral edema C.) Clubbing of the fingers D.) Cyanosis

Answer: C.) Clubbing of the fingers

A client appears to be breathing faster than during the last assessment. Which of the following actions should the nurse perform? A.) Inquire if there have been any stressful visitors. B.) Assist the client to lie down. C.) Count the rate of respirations. D.) Assess the radial pulse.

Answer: C.) Count the rate of respirations.

A nurse practitioner diagnosed a patient with an infection in the maxillary sinuses. Select the area that the nurse palpated to make that diagnosis. A.) Above the eyebrows B.) Between the eyes and behind the nose C.) On the cheeks below the eyes D.) Behind the ethmoid sinuses

Answer: C.) On the cheeks below the eyes

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? A.) Arterial blood gases B.) Pulmonary function test C.) Pulse oximetry D.) Chest x-ray

Answer: C.) Pulse oximetry Rationale: 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? A.) Crackles B.) Pleural friction rub C.) Rhonchi D.) Bronchial

Answer: C.) Rhonchi

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? A.) The nursing assistant is assisting the client to a semi-Fowler's position. B.) The nursing assistant is assisting the client to the side of the bed to use a urinal. C.) The nursing assistant is pouring a glass of water to wet the client's mouth. D.) The nursing assistant is asking a question requiring a verbal response.

Answer: C.) The nursing assistant is pouring a glass of water to wet the client's mouth. Rationale: 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.

Perfusion refers to blood supply to the lungs, through which the lungs receive nutrients and oxygen. What are the two methods of perfusion? A.) The two methods of perfusion are the bronchial and alveolar circulation. B.) The two methods of perfusion are the bronchial and capillary circulation. C.) The two methods of perfusion are the bronchial and pulmonary circulation. D.) The two methods of perfusion are the alveolar and pulmonary circulation.

Answer: C.) The two methods of perfusion are the bronchial and pulmonary circulation. Rationale: The two methods of perfusion are the bronchial and pulmonary circulation. There is no alveolar circulation. Capillaries are the vessels that performs the perfusion regardless of which area of the lung they are in.

Which term refers to the volume of air inhaled or exhaled during each respiratory cycle? A.) Vital capacity B.) Functional residual capacity C.) Tidal volume D.) Maximal voluntary ventilation

Answer: C.) Tidal volume

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? A.) Rales B.) Crackles C.) Wheezes D.) Rhonchi

Answer: C.) Wheezes

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? A.) "I will feel a dull pain when the catheter is introduced." B.) "I will feel light-headed when the contrast medium is introduced." C.) "I will feel waves of nausea throughout the procedure." D.) "I will feel warm and may have chest pain"

Answer: D.) "I will feel warm and may have chest pain" Rationale: 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 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? A.) 40% B.) 75% C.) 80% D.) 95%

Answer: D.) 95%

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)? A.) Tumor densities can be seen with radiolucent images. B.) Narrow-beam x-ray can scan successive lung layers. C.) Lung blood flow can be viewed after a radiopaque agent is injected. D.) MRI can view soft tissues and can help stage cancers.

Answer: D.) MRI can view soft tissues and can help stage cancers. Rationale: 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.

Upon palpation of the sinus area, what would the nurse identify as a normal finding? A.) Light not going through the sinus cavity B.) Pain sensation behind the eyes C.) Tenderness during palpation D.) No tenderness during palpation

Answer: D.) No tenderness during palpation

When assessing a client, which adaptation indicates the presence of respiratory distress? A.) Respiratory rate of 14 breaths per minute B.) Productive cough C.) Sore throat D.) Orthopnea

Answer: D.) Orthopnea