NUR 220 EXAM 2 Gas Exchange

acute cough could lasts

less than 3 weeks

A nurse finds the patient's anteroposterior diameter of the chest to be the same as the lateral diameter. Based on this finding, what additional data would the nurse anticipate? 1. Bronchial breath sounds in the posterior thorax 2. Decrease in respiratory rate 3. Decreased breath sounds on auscultation

3

A nurse is palpating the lymph nodes of an 18-month-old toddler and finds enlarged postauricular and occipital nodes. What is the significance of this finding? 1. This is a normal finding at this age. 2. The toddler may have an ear infection. 3. The toddler may have an inflammation of the scalp. 4. The toddler needs to be referred to a pediatrician.

1

Narrowing of the bronchi creates which adventitious sound? 1. Wheeze 2. Crackles 3. Rhonchi 4. Pleural friction rub

1

On auscultation of a patient's lungs, the nurse hears a low-pitched, coarse, loud, and low snoring sound. Which term does the nurse use to document this finding? 1. Rhonchi 2. Wheeze 3. Crackles 4. Pleural friction rub

1

What would be an abnormal finding for a 7-year-old African American boy? 1. Abdominal distention 2. Umbilical hernia 3. Abdominal breathing 4. Tenseness of abdominal muscles

1

Which finding on a 2-month-old baby is considered abnormal and requires further follow-up? 1. The anterior fontanelle is not palpable. 2. The thyroid gland cannot be palpated. 3. The head circumference is slightly greater than the chest circumference. 4. Head lag is observed when the shoulders are lifted off the examination table.

1

while auscultating a patient's lungs, the nurse notes diminished breath sounds at the base of the right lung. What action should the nurse take next?

listen to the base of the patients left lung.

Which breath sounds are expected over the posterior chest of an adult? 1. Vesicular 2. Bronchovesicular 3. Bronchial 4. Bronchoalveolar

1.

A 3-year-old boy in respiratory distress is treated in the emergency department. A diagnosis of acute spasmodic laryngitis (spasmodic croup) is made. At the time of discharge, the mother asks how to handle another attack at home. What should the nurse recommend? 1 Placing him near a cool-mist humidifier 2 Bringing him to the emergency department 3 Giving him an over-the-counter cough syrup 4 Offering him warm tea sweetened with honey

1. placing him near a cool mist humidifier

auscultation of lung sounds posteriorly-- one should assess how many locations??

10 locations

A nurse is auscultating the lungs of a healthy female patient and hears crackles on inspiration. What action can the nurse take to ensure this is an accurate finding? 1. Make sure the bell of the stethoscope is used rather than the diaphragm. 2. Ask the patient to cough then repeat the auscultation. 3. Ask the patient not to talk while the nurse is listening to the lungs. 4. Change the patient's position to ensure accurate sounds.

2

A nurse suspects a viral infection or upper respiratory allergies when the patient describes the sputum as being which color? 1. White 2. Clear 3. Yellow 4. Pink tinged

2

Which finding of a preschooler during a cardiovascular system examination is abnormal? 1. Heart rate of 106 beats/min 2. Failure to gain weight because of fatigue while eating 3. Continuous low-pitched vibration heard over the jugular vein 4. Pulse increasing on inspiration and decreasing on expiration

2

anterior peripheral vesicular sounds are located

lung fields starting from clavicles

A client is admitted for dehydration, and an intravenous (IV) infusion of normal saline is started at 125 mL/hour. One hour later, the client begins screaming, "I can't breathe!" How should the nurse respond? 1 Discontinue the IV and notify the healthcare provider. 2 Elevate the head of the client's bed and obtain vital signs. 3 Assess the client for allergies and change the IV to an intermittent lock. 4 Contact the healthcare provider to request a prescription for a sedative

2. elevate the head of the clients bed and obtain vital signs

A nurse is caring for a client experiencing an acute episode of bronchial asthma. What should nursing interventions achieve? 1 Curing the condition permanently 2 Raising mucous secretions from the chest 3 Limiting pulmonary secretions by decreasing fluid intake 4 Convincing the client that the condition is emotionally based

2. raising mucous secretions from the chest

see-saw breathing

movement of chest and abdomens in oppsite direction-- abnormal

A patient has an infection of the terminal bronchioles and alveoli that involves the right lower lobe of the lung. Which abnormal findings are expected? 1. Dyspnea with diminished breath sounds bilaterally 2. Asymmetric chest expansion on the right side 3. Fever and tachypnea with crackles over the right lower lobe 4. Prolonged expiration with an occasional wheeze in the right lower lobe

3

An adolescent tells a nurse that, while he was riding in a friend's car, the friend was stopped by the police for driving while intoxicated. Which assessment tool would be most appropriate to use with this adolescent? 1. Faces Pain Scale 2. Pediatric Symptom Checklist (PSC) 3. Guidelines for Adolescent Prevention (GAP) 4. Oucher Scales

3

Which question gives the nurse further information about the patient's complaint of chest pain? 1. "Have you had your influenza immunization this year?" 2. "Are there environmental conditions that may affect your breathing at home?" 3. "How would you describe the chest pain?" 4. "Has the chest pain been interrupting your sleep?"

3

While examining the ear of an infant with an otoscope, the nurse pulls down on the ear for which reason? 1. Increases the depth that the otoscope can be inserted 2. Stabilizes the ear to avoid injury if the infant moves the head suddenly 3. Enhances visualization of the tympanic membrane by straightening the ear canal 4. Facilitates drainage of cerumen from the ear canal, allowing better visualization of inner ear structures

3

newborns are nose breathers until what age?

3 months

The healthcare provider prescribes theophylline to be given intravenously for the client experiencing an acute asthma attack. What does the nurse teach the client is the function of this medication? 1 Antibiotic 2 Antihistamine 3 Bronchodilator 4 Expectorant

3. bronchodilator

What is the normal value of inspiratory reserve volume?

3.0 L

respiratory rate of newborns is

30-60 breaths/min

During inspection of the respiratory system the nurse documents which finding as abnormal? 1. Skin color consistent with patient's ethnicity 2. 1:2 ratio of anteroposterior to lateral diameter 3. Respiratory rate is 20 breaths per minute 4. Patient leaning forward with arms braced on the knees

4

How does the nurse palpate the chest for tenderness, bulges, and symmetry? 1. Uses the fist of the dominant hand to gently tap the anterior, lateral, and posterior chest, comparing one side with another 2. Uses the ulnar surface of one hand to palpate the anterior, posterior, and lateral chest, comparing one side with another 3. With the tips of the fingers, palpates the skin over the chest and the alignment of vertebrae 4. With the palmar surface of fingers of both hands, feels the consistency of the skin over the chest and the alignment of vertebrae

4

On assessment of the neurologic status of a 4-month-old infant, the nurse notes which finding as abnormal? 1. The infant abducts and extends arms and legs when startled. 2. When the infant's sole is touched, the toes flex tightly in an attempt to grasp. 3. When stroking the infant's foot from sole to great toes, there is fanning of the toes. 4. The infant steps in place when held upright with feet on a flat surface.

4

What is an expected finding of the newborn's vision that the nurse teaches the parents? 1. Small tears will be noted when their newborn cries. 2. Peripheral sight does not develop until age 3 or 4 months. 3. The newborn can only distinguish the colors of blue and green. 4. The newborn is nearsighted and cannot see items unless they are close.

4

When examining the genitalia of a 3-year-old boy, which position is ideal? 1. Prone position with legs flexed in a frog leg position 2. Supine position with knees spread and ankles spread apart 3. Lithotomy position with knees and ankles spread apart 4. Sitting position with knees spread and ankles crossed

4

Which are expected findings of a newborn's respiratory assessment? 1. Thoracic breathing 2. A 1:2 ratio of anteroposterior-to-lateral diameter 3. Flaring of the nares noted on inspiration 4. Bronchovesicular breath sounds in the peripheral lung fields

4

A client had surgery for a ruptured appendix. Postoperatively, the health care provider prescribes an antibiotic to be administered intravenously twice a day. The nurse administers the prescribed antibiotic via a secondary line into the primary infusion of 0.9% sodium chloride. During the administration of the antibiotic, the client becomes restless and flushed, and begins to wheeze. What should the nurse do after stopping the antibiotic infusion? 1 Check the client's temperature. 2 Take the client's blood pressure. 3 Obtain the client's pulse oximetry. 4 Assess the client's respiratory status.

4. assess the clients respiratory status

When caring for a client who has acute respiratory distress syndrome (ARDS), the nurse would implement which measure to promote effective airway clearance? 1 Administer sedatives around the clock 2 Turn client every four hours 3 Increase ventilator settings as needed 4 Suction as needed

4. suction as needed

auscultation of lung sounds anteriorly--one should assess how many locations??

8 locations

A client is admitted to the hospital with partial- and full-thickness burns of the chest and face sustained while trying to extinguish a brush fire. Which is the nurse's priority concern? 1Loss of skin integrity caused by the burns 2Potential infection as a result of the burn injury 3 Inadequate gas exchange caused by smoke inhalation 4 Decreased fluid volume because of the depth of the burns

Inadequate gas exchange caused by smoke inhalation

The parents of a child with spasmodic croup ask why their child is receiving humidified oxygen. What effect of humidified oxygen should the nurse include in the explanation? 1. Minimizes tissue edema 2 Provides a mode of giving inhalant drugs 3 Increases the surface tension of the respiratory tract 4 Provides an environment free of pathogenic organisms

Minimizes tissue edema

all newborns are ______________ breathers

abdominal

rust sputum

TB or pneumococcal pneumonia

A nurse is teaching a client with a diagnosis of pulmonary tuberculosis about recovery after discharge. What is the most important intervention for the nurse to include in this plan? 1 Ensuring sufficient rest 2 Changing lifestyle routines 3 Breathing clean outdoor air 4 Taking medications as prescribed

Taking medications as prescribed

personal/psychosocial history

air pollution home allergens HVAC system hobbies travel

the nurse receives a telephone call from the post-anesthesia care unit stating that a client is being transferred to the surgical unit. The nurse plans to take which action first on arrival of the client?

assess the potency of the airway

fremitus

a palpable vibration from the spoken voice felt over the chest wall felt from palpating the back

yellow/green sputum

infection

anterior bronchovesicular sounds are located..

central area of sternum

clubbing of nails can indicate

chronic hypoxia

chronic health history

chronic illness allergies difficulty breathing meds smoking

high pitched cracking popping noises at end of inspiration, not cleared with cough

crackles

Feeling for vibration when one says ninety nine

fremitus

chronic cough lasts

greater than 3 weeks

the nurse understands that which statement is correct regarding respiratory rates?

healthy adults breathe between 12-20 times a minute

family

helps determine patients risk for these diseases

is palpation of lung sounds performed on newborns?

no, only inspection and vital signs

clear sputum

normal/allergies

anterior bronchial sounds are located

over trachea (throat area)

low pitched, coarse, rubbing or grating sound, heard in inspiration/expiration

pleural friction rub

posterior vesicular sounds are located

posterior lung fields

past medical history

problems with lungs respiratory diseases injury/surgery

low pitched, coarse, loud, low snoring or moaning tone, cough may clear

rhonchi

dyspnea

shortness of breath

black sputum

smoke or coal dust inhalation

poor posture can decrease respiratory

status

pack-years

the number of packs per day multiplied by the number of years the patient has smoked

At 6/7 years old child changes from nasal breathing to..

thoracic for girls diaphragmatic for boys

posterior bronchovesicular sounds

upper center of back between scapulae

high pitched musical sounds similar to squeak, more common during expiration

wheezes