Health alterations-respiratory
Which part of the respiratory system is referred to as Angle of Louis?
Carina
mediastinoscopy
(lung biopsy) may not require the client to be seated upright. No special precautions are needed after performing ventilation-perfusion scan because the gas and isotope transmits radioactivity for only a brief interval.
Which order of actions should a nurse follow when performing a chest examination of a client with a pulmonary disorder?
1. Observe for any evidence of respiratory distress. 2. Observe the shape and symmetry of the chest 3. Observe for any abnormalities of the sternum 4. Monitor the respiratory rate
What is the normal value of functional residual capacity?
2.5L
What is the normal value of inspiratory reserve volume?
3.0 L
The nurse places a pulse oximetry probe on the finger and toe of a client with a respiratory disorder to determine the oxygen saturation of hemoglobin (SpO2). Which other parameter can be determined using this technique?
Arterial oxygen saturation
A client who was recently diagnosed with emphysema develops a malignancy in the right lower lobe of the lung, and a lobectomy is performed. After surgery, the client is receiving oxygen by nasal cannula at 2 L per minute. Blood gas results demonstrate respiratory acidosis. What should be the initial nursing intervention?
Encourage deep breathing
Which part of the upper respiratory system is involved in equalizing the pressure within the middle ear while swallowing?
Eustachian tubes
Which pulmonary function test provides a more sensitive index of obstruction in smaller airways?
Forced expiratory flow over the 25% to 75% volume of the forced vital capacity
bronchial breath sounds
High pitch with a loud, harsh, tubular quality; inspiration half as long as expiration
A client with a history of hemoptysis and cough for the last six months is suspected of having lung cancer. A bronchoscopy is performed. Two hours after the procedure the nurse identifies an increase in the amount of bloody sputum. What is the nurse's priority?
Immediately contact the health provider
A nurse is caring for a client who was admitted to the hospital with a diagnosis of chronic obstructive pulmonary disease and is receiving oxygen at 2 L/min via nasal cannula. What is the primary focus of therapy when caring for this client?
Improving ventilation
Which chest examination findings can be observed in a client with pneumonia?
Increased fremitus over affected area on palpation
vesicular breath sounds
Low to medium pitch with a soft whooshing quality; inspiration is two to three times the length of expiration
bronchovesicular breath sounds
Moderate to high pitch with a hollow, muffled quality; equal time of inspiration and expiration
Which criteria should the primary healthcare provider use for the prescription of long-term continuous oxygen therapy?
PaO2-55, SpO2- 88
The client has just had a chest tube inserted. How should the nurse monitor for the complication of subcutaneous emphysema?
Palpate around the tube insertion sites for crepitus
A client with chronic obstructive pulmonary disease (COPD) has a blood pH of 7.25 and a PCO2 of 60 mm Hg. What complication does the nurse conclude the client is experiencing?
Respiratory acidosis
Flat sound
Soft high-pitched sounds of short duration heard over very dense tissue where air is not present
Tympany
Sounds with drum-like, loud, or empty quality heard over a gas-filled stomach or intestines
The nurse is caring for a client with a possible pulmonary embolism (PE). Which diagnostic test should the nurse initially anticipate will be prescribed for this client because it is the evidence-based gold standard for a PE diagnosis?
Spiral (helical) computed tomographic angiography (CTA)
An older client complains of confusion, dry mouth, and constipation. The client was treated for rhinitis a week ago and is taking chlorpheniramine. Which information provided by the nurse would be beneficial to the client?
These are common side effects of chlorpheniramine
Cheyne-Stokes respirations
abnormal respirations with alternating periods of apnea and rapid breathing
A client who is receiving peritoneal dialysis reports severe respiratory difficulty. What immediate action should the nurse implement?
auscultate the lungs
A nurse receives a call from the emergency department about a client with tuberculosis (TB) who will be admitted to the medical unit. Which precaution should the nurse take?
Wear a particulate respirator when caring for the client
Resonance
a low-pitched sound heard over the lungs during percussion in healthy individuals. Breathing sounds may be considered dull if sounds are of medium-intensity pitch and duration and are heard over areas of mixed, solid, and lung tissue.
performed for diagnosis of lesions difficult to assess by conventional X-ray studies
computed tomography
What is a spirometer used for?
hand-held device that can be used at home. A client blows forcefully and quickly into the device after taking a deep breath. This device is used to diagnose early lung transplant rejections or infections and helps to monitor lung function.
Capnography
helps to assess the level of CO2 in exhaled air; this device graphically displays the amount of partial pressure of CO2. Ventilation-perfusion is used to assess the ventilation and perfusion of the lungs
pursed lip breathing
increases positive pressure within the alveoli and makes it easier for clients to expel air from the lungs. This in turn promotes elimination of CO2. It also helps clients to slow their breathing pattern and depth with respirations. It does not decrease chest pain, conserve energy, or increase oxygen saturation.
thorencentesis
performed to obtain a specimen of pleural fluid for diagnosis. The client should be positioned upright with elbows on an overbed table with the feet supported. The client should not talk or cough during the procedure because the inserted needle may cause trauma.
used to visualize pulmonary vasculature and locate obstruction of pathologic conditions.
pulmonary angiogram
Kussmaul respirations
rapid and deep breathing abnormality
When caring for a client who has acute respiratory distress syndrome (ARDS), the nurse would implement which measure to promote effective airway clearance?
suction as needed
Expiratory Reserve volume
the additional air that can be forcefully exhaled after normal exhalation
Inspiratory Reserve Volume
the additional air that can be forcefully inhaled after normal inhalation.
Tidal Volume
the volume of air inhaled and exhaled with each breath. Residual volume is the amount of air remaining in the lungs after forced expiration.
magnetic resonance imaging (MRI)
used for distinguishing vascular from nonvascular structures. An X-ray is useful to screen, diagnose, and evaluate changes in the respiratory system.
Forced expiratory volume/forced vital capacity ratio
useful in differentiating between obstructive and restrictive pulmonary dysfunction.
When is a nonrebreather mask used?
when the client requires higher oxygen concentrations and the condition is worsening. If the nonrebreathing mask does not improve oxygen saturation, the next steps to improving gas exchange and oxygenation are intubation and mechanical ventilation