Oxygenation Chapter 50

During the annual physical exam for an older adult client at the clinic, the nurse includes which question in the focused interview to assess for common respiratory problems? (1point) "Are your immunizations up to date?" "Do you have food allergies?" "How often do you see your healthcare provider?" "Do you take any supplements?"

"Are your immunizations up to date?" Rationale: Older adults are at risk for respiratory infections. Immunizations for pneumonia and influenza are important in assessing risk for infections common in this population.

The nurse is formulating questions for a focused interview to assess a college student who has presented to the college medical center with a new onset of dry cough. Which questions should the nurse include in this assessment? (Select all that apply.) "Do you take a vitamin supplement?" "What color is the sputum produced?" "Do you have pain with the cough?" "Do you smoke cigarettes or marijuana?" "How much sleep do you get?"

"Do you have pain with the cough?" Rationale: The client has already described the cough as dry. Smoking is an irritant that can cause cough. Pain is an important cough-related symptom to evaluate. Use of supplements is important, but not a priority in this situation. Sleep disruption due to the cough is important to evaluate. "Do you smoke cigarettes or marijuana?" "How much sleep do you get?"

For which client would the nurse suggest tuberculin skin testing? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. (1point) A client with a congenital heart defect A client living in a rural area of the United States A client who is HIV positive A client who has traveled extensively throughout the world A recent immigrant from South America

A client who is HIV positive A client who has traveled extensively throughout the world A recent immigrant from South America Score: 1 Feedback: Rationale: Immigrants are at higher risk for tuberculosis (TB) infection than the general population. Clients with congenital anomalies are not at higher risk for TB. Clients with a positive HIV test are at higher risk for TB. Urban dwellers are thought to be at higher risk for TB than those who reside in rural communities. Clients who have traveled internationally are thought to be at higher risk for TB

An adult client is visiting the primary care clinic for an annual physical examination. When the nurse is palpating the client's posterior thorax and detects crepitus, this indicates: (1point) Scar tissue from healing of a broken rib. Suspicion for lung cancer. Cellulitis. Air leaking from the thorax into the subcutaneous tissue.

Air leaking from the thorax into the subcutaneous tissue. Rationale: Crepitus is an indication that air is leaking from the thorax into the subcutaneous tissue

A client is admitted to the emergency room with the pictured condition. The nurse would expect these assessment findings in this client: (Select all that apply.) Diminished voice sounds. Symmetrical chest expansion. Possible pleural rub. Tympany on percussion. Dyspnea.

Diminished voice sounds. Possible pleural rub. Dyspnea. Rationale: Dyspnea is common with pleural effusion. Chest expansion in pleural effusion is likely asymmetrical. Percussion on the affected side would be dull over the fluid-filled areas. Pleural rub is possible with pleural effusion. Diminished voice and breath sounds are likely with pleural

The nurse is performing a respiratory assessment on a client with a long smoking history and documentation that supports chronic inflammation of the lungs, destruction of alveoli, and decreased elasticity of the lungs. The nurse is aware that this condition is likely: Asthma. Emphysema. Chronic bronchitis. Pneumonia.

Emphysema. Rationale: Emphysema is defined as a condition in which chronic inflammation of the lungs leads to destruction of alveoli and decreased elasticity of the lungs ultimately leading to trapped

Which action by the nurse will reduce the risk of respiratory deaths in infants and children? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. (1point) Encourage parents of infants to vary the child's sleeping positions. Encourage frequent hand hygiene in day care providers. Lobby for restrictions on smoking in public places. Teach caregivers to select toys appropriate to age and developmental stage. Discourage immunization of children with congenital anomalies.

Encourage frequent hand hygiene in day care providers. Rationale: Exposure to second-hand smoke increases risk for respiratory disease in children. The recommended sleeping position for infants is on their backs. Immunization against communicable diseases is strongly encouraged for all children. Hand hygiene is an important measure in preventing infection. Inappropriate toys put children at risk for choking and aspiration. Lobby for restrictions on smoking in public places. Teach caregivers to select toys appropriate to age and developmental stage.

The nurse correctly attributes natural reductions in the respiratory efficiency in older adult clients to: (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. (1point) Poor nutrition. Loss of lung elasticity. Muscle weakness.

Loss of lung elasticity. Muscle weakness

The nurse performs whispered pectoriloquy while assessing a client who has presented at the emergency department. While auscultating the client's breath sounds at various levels, the words "1, 2, 3" sound loud and clear. The nurse interprets the finding to indicate areas of: (1point) Pleurisy. Normal tissue. Tumor. Lung consolidation

Lung consolidation. Rationale: When the client says "1, 2, 3" each time the nurse places the stethoscope on the chest, and the words sound loud and clear, the nurse interprets the finding as characteristic of lung consolidation.

To ensure client safety during the respiratory exam of a new client to the primary care clinic, the nurse should instruct the client to: (1point) Breathe deeply through the mouth. Refrain from eating for 6 hours before the exam. Notify the nurse if dizziness occurs. Remain seated for 30 minutes after the exam is complete.

Notify the nurse if dizziness occurs. Rationale: The client can become faint or dizzy during the exam and should be instructed to notify Rationale: The client should breathe normally during percussion. Asking the client to lean forward helps to increase the area to percuss. Rounding the shoulders moves the scapulae out of the way to increase area for percussion. Performing the Valsalva maneuver is not necessary for percussion. Asking the client to cough may interfere with the nurse's ability to perform percussion

The nurse knows that the trachea bifurcates at which anatomical point?

Rationale: The jugular notch is not the point of tracheal bifurcation. The manubrium is not the point of tracheal bifurcation. The xiphoid process is not the point of tracheal bifurcation. Cognitive Level: Remembering Nursing Process: Assessment Client Need: Physiological Integrity Rationale: The jugular notch is not the point of tracheal bifurcation. The manubrium is not the point of tracheal bifurcation. The xiphoid process is not the point of tracheal bifurcation. Cognitive Level: Remembering Nursing Process: Assessment Client Need: Physiological Integrity Rationale: The sternal angel is the point of tracheal bifurcation. Cognitive Level: Remembering Nursing Process: Assessment Client Need: Physiological Integrity Rationale: The jugular notch is not the point of tracheal bifurcation. The manubrium is not the point of tracheal bifurcation. The xiphoid process is not the point of tracheal bifurcation

The nurse is examining the client who has presented at the clinic with complaints of trouble breathing. Identify the area where the nurse should place the stethoscope to auscultate for normal bronchovesicular breath sounds.

Rationale: Bronchovesicular breath sounds are heard near the bifurcation of the trachea, which is around the 2nd intercostal space anteriorly.

A client has an infection of the lower respiratory system. Click on the labels in which the infection could reside. (Select all that apply.)

Rationale: Part of the trachea is included in the lower respiratory system. Cognitive Level: Applying Nursing Process: Assessment Client Need: Physiological Integrity Rationale: The mainstem bronchus is part of the lower respiratory system. Cognitive Level: Applying Nursing Process: Assessment Client Need: Physiological Integrity Rationale: The left lung is part of the lower respiratory system.

Select the site of gas exchange in the lung.

Rationale: The alveoli are the site of gas exchange.

The nurse is to percuss the client's posterior thorax during an examination of a hospitalized 70-year-old client. Which directions should the nurse include to prepare the client for this part of the examination? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. (1point) Round the shoulders. Lean forward. Hold a deep breath and bear down. Breathe normally. Cough vigorously.

Round the shoulders. Lean forward. Breathe normally.

The nurse assesses for voice sounds as a part of respiratory assessment. Examples of voice sound assessment include: (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. (1point) Whispered pectoriloquy. Bronchovesicular. Rhonchi. Egophony. Bronchophony.

Whispered pectoriloquy. Egophony. Bronchophony. Rationale: Bronchophony is a test of voice sounds. Bronchovesicular is a normal breath sound. Egophony is a test of voice sounds. Whispered pectoriloquy is a test of voice sounds. In normal lung tissue, the sound will be faint. Rhonchi are adventitious breath sounds

When the nurse measures the client's respiratory rate at 16 respirations per minutes, the nurse recognizes that the value is normal when found in a(n): (1point) Young adult. Toddler. Newborn. School-aged child.

Young adult Rationale: Respiratory rates of 12-20 breaths per minute are normal for an adult.