Chapter 20 (Test 3)

You are 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 puncture at the radial artery

The nurse working in the radiology clinic is assisting with a pulmonary angiography. The nurse knows that when monitoring clients after a pulmonary angiography, what should the physician be notified about?

Absent distal pulses

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?

Abstain from food for at least 6 hours before the procedure.

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?

Asthma

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

Barrel chest

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

Clubbing of the fingers

A son brings his father into the clinic, stating that his father's color has changed to bluish around the mouth. The father is confused, with a respiratory rate of 28 breaths per minute and scattered crackles throughout. The son states this condition just occurred within the last hour. Which of the following factors indicates that the client's condition has lasted for more than 1 hour?

Cyanosis

Which of the following is a late sign of hypoxia?

Cyanosis

The nurse is completing a physical assessment of a patient's trachea. The nurse inspects and palpates the trachea for which of the following?

Deviation from the midline

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?

Diagnosis of 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

A nurse is preparing a client for bronchoscopy. Which instruction should the nurse give to the client?

Don't eat

A 6-month-old male client and his elder brother, a 3-year-old male, are being seen in the pediatric clinic for their third middle ear infection of the winter. The mother reports they develop an upper respiratory infection and an ear infection seems quick to follow. What contributes to this event?

Eustachian tubes

A nurse is concerned that a client may develop postoperative atelectasis. Which nursing diagnosis would be most appropriate if this complication occurs?

Impaired gas exchange

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?

Orthopnea

Which of the following terms will the nurse use to document the inability of a patient to breathe easily unless positioned upright?

Orthopnea

The nurse is reviewing the blood gas results for a patient with pneumonia. What arterial blood gas measurement best reflects the adequacy of alveolar ventilation?

PACO2

A patient describes his chest pain as knife-like on inspiration. Which of the following is the most likely diagnosis?

Pleurisy

The nurse is caring for a patient who is to undergo a thoracentesis. In preparation for the procedure, the nurse will position the patient in which of the following positions?

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?

Swallow reflex

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 a funnel chest.

The client is returning from the operating room following a broncho scopy. 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.

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?

The pons

The nurse is caring for a client diagnosed with asthma. While performing the shift assessment, the nurse auscultates breath sounds including sibilant wheezes, which are continuous musical sounds. What characteristics describe sibilant wheezes?

They can be heard during inspiration and expiration

Which of the following alveolar cells secrete surfactant?

Type II

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

Use of accessory muscles

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?

Ventilation exceeds perfusion.

What is the difference between respiration and ventilation?

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

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)?

Vital capacity of 3,000 mL

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

Warm and humidify inspired air

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.