Chapter 20: Assessment of Respiratory Function Prep U

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 repeat "ninety-nine" as the nurse's hands move down the client's thorax Placing the thumbs along the costal margin of the chest wall and instructing the client to inhale deeply Asking the client to say "one, two, three" while the nurse auscultates the lungs 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

The nurse inspects the thorax of a patient with advanced emphysema. What does the nurse expect the chest configuration to be for this patient? Pigeon chest Kyphoscoliosis Barrel chest Funnel chest

Barrel chest

Which is a deformity of the chest that occurs as a result of overinflation of the lungs? Pigeon chest Barrel chest Funnel chest Kyphoscoliosis

Barrel chest

A client with sinus congestion complains of discomfort when the nurse is palpating the supraorbital ridges. What sinus is the client referring? Ethmoidal Maxillary Frontal Sphenoidal

Frontal

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

Orthopnea

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? Wernicke's area The frontal lobe The pons Central sulcus

The pons

A nurse is assessing a client's respiratory system. Which alveolar cells secrete surfactant to reduce lung surface tension? Type I Type II Macrophages Type IV

Type II

What is the difference between respiration and ventilation? Ventilation is the process of gas exchange. 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 movement of air in and out of the respiratory tract.

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

Diaphragm contracts and elongates the chest cavity.

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

On the cheeks below the eyes

In which position should the client be placed for a thoracentesis? Sitting on the edge of the bed Supine Prone Lateral recumbent

Sitting on the edge of the bed

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 Sitting on the edge of the bed Lateral recumbent Supine

Sitting on the edge of the bed

The nurse is admitting a client who just had a bronchoscopy. Which assessment should be the nurse's priority? Medication allergies Swallow reflex Presence of carotid pulse Ability to deep breathe

Swallow reflex

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 II cells Type IV cells Type III cells Type I cells

Type II cells

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

"I will feel warm and may have chest pain"

A nurse is assessing a client's respiratory system. Which alveolar cells secrete surfactant to reduce lung surface tension? Type IV Macrophages Type I Type II

Type II

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

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

Crackles at lung bases

During a preadmission assessment, for what diagnosis would the nurse expect to find decreased tactile fremitus and hyperresonant percussion sounds? Pulmonary edema Bronchitis Atelectasis Emphysema

Emphysema

The client has just had an invasive procedure to assess the respiratory system. What does the nurse know should be assessed on this client? Watery sputum Masses in pleural space Respiratory distress Loss of consciousness

Respiratory distress

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. 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 asking a question requiring a verbal response.

The nursing assistant is pouring a glass of water to wet the client's mouth.

The nurse is completing a physical assessment of a client's trachea. The nurse inspects and palpates the trachea for evidence of exudate. evidence of muscle weakness. deviation from the midline. color of the mucous membranes.

deviation from the midline.

The volume of air inhaled and exhaled with each breath is termed expiratory reserve volume. residual volume. tidal volume. vital capacity.

tidal volume.

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 11. 22. 10. 5.

22

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? Placement of the probe on an earlobe Diagnosis of peripheral vascular disease Increased temperature of the room Reduced lighting in the room

Diagnosis of peripheral vascular disease

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: lips. mucous membranes. nail beds. earlobes.

mucous membranes.

Pink, frothy sputum may be an indication of an infection. pulmonary edema. a lung abscess. bronchiectasis.

pulmonary edema.

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? 75% 80% 40% 95%

95%

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. Posterior surface of the left side of the chest, near the sixth rib. Anterior 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 right side of the chest, between the fourth and fifth rib.

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? Right lower lobe Posterior bronchioles Bilateral lower lobes Anterior bronchial tree

Bilateral lower lobes

What finding by the nurse may indicate that the client has chronic hypoxia? Crackles Peripheral edema Cyanosis Clubbing of the fingers

Clubbing of the fingers

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 Decreased cardiac output Ineffective airway clearance Impaired gas exchange

Impaired gas exchange

The nurse is in the radiology unit of the hospital. The nurse is caring for a client who is scheduled for a lung scan. The nurse knows that lung scans need the use of radioisotopes and a scanning machine. Before the perfusion scan, what must the client be assessed for? Inflammation Dysrhythmias Bleeding Iodine allergy

Iodine allergy

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? Client reports no chest pain. Lungs are clear on auscultation. Client can perform incentive spirometry. Respiratory rate is 12 to 18 breaths per minute.

Lungs are clear on auscultation

A patient comes to the emergency department complaining of a knifelike pain when taking a deep breath. What does this type of pain likely indicate to the nurse? Bacterial pneumonia Lung infarction Bronchogenic carcinoma Pleurisy

Pleurisy

The clinical finding of pink, frothy sputum may be an indication of which condition? Bronchiectasis Infection Lung abscess Pulmonary edema

Pulmonary edema

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 II cells Type III cells Type I cells Type IV cells

Type II cells

A patient's lung volumes and capacities were assessed to help determine the cause of a respiratory problem. Which of the following findings are indicative of chronic obstructive pulmonary disease (COPD)? Residual volume of 1,200 mL Functional residual capacity of 2,300 mL Vital capacity of 3,000 mL Expiratory reserve volume of 1,100 mL

Vital capacity of 3,000 mL

A nurse is preparing a client with a pleural effusion for a thoracentesis. The nurse should: raise the head of the bed to a high Fowler's position. 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. assist the client to a sitting position on the edge of the bed, leaning over the bedside table.

assist the client to a sitting position on the edge of the bed, leaning over the bedside table.

A nurse would question the accuracy of a pulse oximetry evaluation in which of the following conditions? A client on a ventilator with PEEP A client sitting in a chair after prolonged bed rest A client experiencing hypothermia A client receiving oxygen therapy via Venturi mask

A client experiencing hypothermia

Which is a true statement regarding air pressure variances? The thoracic cavity becomes smaller during inspiration. The diaphragm relaxes during inspiration. Air is drawn through the trachea and bronchi into the alveoli 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.

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? Adult respiratory distress syndrome Pneumothorax Acute respiratory obstruction Asthma

Asthma

The nurse is assessing a patient in respiratory failure. What finding is a late indicator of hypoxia? Clubbing of fingers Restlessness Cyanosis Crackles

Cyanosis

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 Urge to cough Hematoma Absent distal pulses

Difficulty in breathing

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? Dull Tympanic Hyperresonant Resonant

Dull

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

MRI can view soft tissues and can help stage cancers.

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

No sensation during palpation

Which term will the nurse use to document the inability of a client to breathe easily unless positioned upright? Hemoptysis Dyspnea Hypoxemia Orthopnea

Orthopnea

Which diagnostic imaging modality is more accurate than computed tomography in detecting malignancies? Gallium scan MRI Pulmonary angiography PET

PET

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? Chest x-ray Pulmonary function test Pulse oximetry Arterial blood gases

Pulse oximetry

The client has just had an invasive procedure to assess the respiratory system. What does the nurse know should be assessed on this client? Watery sputum Respiratory distress Masses in pleural space Loss of consciousness

Respiratory distress

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? Venous hum Rales Bronchovesicular Rhonchi

Rhonchi

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? Rhonchi Crackles Pleural friction rub Bronchial

Rhonchi

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? Drink 8 oz of water to thin the secretions for expectoration. Take deep breaths and cough forcefully. Use the secretions present in the oral cavity. Tickle the back of the throat to produce the gag reflex.

Take deep breaths and cough forcefully.

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 result from air passing through widened air passages. They are heard in clients with decreased secretions. They occur when the pleural surfaces are inflamed. They can be heard during inspiration and expiration.

They can be heard during inspiration and expiration.

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

Use of accessory muscles

What is the difference between respiration and ventilation? Ventilation is the process of gas exchange. 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 exchange of gases in the lung.

Ventilation is the movement of air in and out of the respiratory tract.

While auscultating the lungs of a client with asthma, the nurse hears a continuous, high-pitched whistling sound on expiration. The nurse will document this sound as which of the following? Crackles Rhonchi Wheezes Pleural friction rub

Wheezes

The nurse answers a client's call light. The client reports an irritating tickling sensation in the throat, a salty taste, and a burning sensation in the chest. Upon further assessment, the nurse notes a tissue with bright red, frothy blood at the bedside. The nurse can assume the source of the blood is likely from the rectum. stomach. nose. lungs.

lungs

It is important for the nurse to provide required information and appropriate explanations of diagnostic procedures to clients with respiratory disorders in order to manage decreased energy levels. aid the client's caregivers. manage respiratory distress. ensure adequate rest periods.

manage decreased energy levels.