Pellico Ch. 8 Nursing Assessment: Respiratory Function (Prep-U)

In a patient diagnosed with increased intracranial pressure (IICP), the nurse would expect to observe which of the following respiratory rate or depth?

Bradypnea Rationale: Bradypnea is a slower than normal rate (<10 breaths/minute), with normal depth and regular rhythm. It is associated with IICP, brain injury, central nervous system depressants, and drug overdose. Tachypnea is associated with metabolic acidosis, septicemia, severe pain, and rib fracture. Hypoventilation is shallow, irregular breathing. Hyperventilation is an increased rate and depth of breathing.

Mr. Sam Wallace, a 53-year-old male, is a regular client in the respiratory group where you practice nursing. As with all adults, millions of alveoli form most of the pulmonary mass. The squamous epithelial cells lining each alveolus consist of different types of cells. Which type of the alveoli cells produce surfactant?

Type II cells Rationale: Type II cells—produce surfactant, a phospholipid that alters the surface tension of alveoli, preventing their collapse during expiration and limiting their expansion during inspiration

The nurse documents breath sounds that are soft, with inspiratory sounds longer than expiratory and found over the periphery of the lungs. Which of the following will the nurse chart?

Vesicular Rationale: Vesicular breath sounds are heard over the entire lung field except the upper sternum and between the scapulae. Their pitch and intensity are low. Inspiration sounds are longer than expiratory sounds. These are considered normal breath sounds.

A nurse enters a client's room and observes a container with sputum. Upon questioning about the specimen, which of the following items of information from the client would necessitate the nurse to obtain a new specimen?

"I coughed that up about 8 hours ago." Rationale: A sputum specimen is obtained for analysis to identify pathogenic organisms. Expectoration is the usual method for collecting a sputum specimen. After a few deep breaths, the client coughs, using the diaphragm, and expectorates into a sterile container. The specimen is delivered to the laboratory within 2 hours. Allowing the specimen to stand for several hours in a warm room results in overgrowth of organisms and may make it difficult to identify the organisms.

Which of the following is a true statement regarding air pressure variances?

Air is drawn through the trachea and bronchi into the alveoli during inspiration. Rationale: Air flows from a region of higher pressure to a region of lower pressure. During inspiration, movement of the diaphragm and other muscles of respiration enlarge the thoracic cavity and thereby lower the pressure inside the thorax to a level below that of atmospheric pressure.

While conducting the physical examination during assessment of the respiratory system, which of the following does a nurse assess by inspecting and palpating the trachea?

Deviation from the midline Rationale: During the physical examination, the nurse must inspect and gently palpate the trachea to assess for placement and deviation from the midline. The nurse examines the posterior pharynx and tonsils with a tongue blade and light and notes any evidence of swelling, inflammation, or exudate, as well as changes in color of the mucous membranes. The nurse also examines the anterior, posterior, and lateral chest walls for any evidence of muscle weakness.

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

Don't eat. Rationale: Bronchoscopy involves visualization of the trachea and bronchial tree. To prevent aspiration of stomach contents into the lungs, the nurse should instruct the client not to eat or drink anything for approximately 6 hours before the procedure. It isn't necessary for the client to avoid walking, talking, or coughing.

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 Rationale: Airflow is decreased with atelectasis, which is a bronchial obstruction from collapsed lung tissue. If there is an obstruction, there is limited or no gas exchange in this area. Impaired gas exchange is thus the most likely nursing diagnosis with atelectasis.

You are performing pulmonary function studies on clients in the clinic. What position do you know a client should be in to have maximum lung capacities and volumes?

In the standing position Rationale: The maximum lung capacities and volumes are best achieved when the client is sitting or standing. Lying on the unaffected side and resting the head on the pillow are the positions recommended for thoracentesis. Lying flat on the back is not applicable for achieving maximum lung capacities and volumes.

Which of the following results in decreased gas exchange in older adults?

The alveolar walls contain fewer capillaries. Rationale: Although the number of alveoli remains stable with age, the alveolar walls become thinner and contain fewer capillaries, resulting in decreased gas exchange. The lungs also lose elasticity and become stiffer. Elasticity of lungs does not increase with age, and number of alveoli does not decrease with age.

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? a) Absent distal pulses b) Flushed feeling in the client c) Raised temperature in the affected limb d) Excessive capillary refill

a) Absent distal pulses Rationale: When monitoring clients after a pulmonary angiography, nurses must notify the physician about diminished or absent distal pulses, cool skin temperature in the affected limb, and poor capillary refill. When the contrast medium is infused, the client will sense a warm, flushed feeling.

Which of the following is a deformity of the chest that occurs as a result of over inflation of the lungs? a) Barrel chest b) Funnel chest c) Kyphoscoliosis d) Pigeon chest

a) Barrel chest Rationale: A barrel chest occurs as a result of over inflation of the lungs. There is an increase in the anteroposterior diameter of the thorax. Funnel chest occurs when there is a depression in the lower portion of the sternum, which may result in murmurs. Pigeon chest occurs as a result of displacement of the sternum resulting in an increase in the anteroposterior diameter. Kyphoscoliosis is characterized by elevation of the scapula and a corresponding S-shaped spine. This deformity limits lung expansion within the thorax.

A patient diagnosed with diabetic ketoacidosis would be expected to have which type of respiratory pattern? a) Kussmaul respirations b) Biot's respirations c) Cheyne-Stokes d) Apnea

a) Kussmaul respirations Rationale: Kussmaul respirations are seen in patients with diabetic ketoacidosis. In Cheyne-Stokes respiration, rate and depth increase, then decrease until apnea occurs. Biot's respiration is characterized by periods of normal breathing (3 to 4 breaths) followed by a varying period of apnea (usually 10 to 60 seconds).

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. Included in teaching would be which of the following regarding the MRI? a) MRI can view soft tissues and can help stage cancers. b) Narrow-beam x-ray can scan successive lung layers. c) Tumor densities can be seen with radiolucent images. d) Lung blood flow can be viewed after a radiopaque agent is injected.

a) MRI can view soft tissues and can help stage cancers. Rationale: MRI uses magnetic fields and radiofrequency signals to produce a detailed diagnostic image. MRI can visualize soft tissues, characterize nodules, and help stage carcinomas. The other options describe different studies.

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

a) Swallow reflex Rationale: The physician sprays a local anesthetic into the client's throat before performing a bronchoscopy. The nurse must assess the swallow reflex when the client returns to the unit and before giving him anything by mouth. The nurse should also assess for medication allergies, carotid pulse, and deep breathing, but they aren't the priority at this time.

The amount of air inspired and expired with each breath is called: a) Tidal volume b) Vital capacity c) Residual volume d) Dead-space volume

a) Tidal volume Rationale: Tidal volume is the amount of air inspired and expired with each breath. Residual volume is the amount of air remaining in the lungs after forcibly exhaling. Vital capacity is the maximum amount of air that can be moved out of the lungs after maximal inspiration and expiration. Dead-space volume is the amount of air remaining in the upper airways that never reaches the alveoli. In pathologic conditions, dead space may also exist in the lower airways.

The term for the volume of air inhaled and exhaled with each breath is a) Tidal volume b) Residual volume c) Vital capacity d) Expiratory reserve volume

a) Tidal volume Rationale: Tidal volume is the volume of air inhaled and exhaled with each breath. Residual volume is the volume of air remaining in the lungs after a maximum expiration. Vital capacity is the maximum volume of air exhaled from the point of maximum inspiration. Expiratory reserve volume is the maximum volume of air that can be exhaled after a normal inhalation.

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? a) Wheezes b) Pleural friction rub c) Crackles d) Ronchi

a) Wheezes Rationale: Wheezes, usually heard on expiration, are continuous, musical, high pitched, and whistle-like sounds caused by air passing through narrowed airways. Often, wheezes are associated with asthma.

A patient has an order for arterial blood gases (ABG) to be drawn? Which of the following tests must be done prior to the procedure? a) Doppler studies b) Allen test c) Angiography d) Pulse oximetry

b) Allen test Rationale: Before obtaining an ABG from the radial artery, it is necessary to test the patency of the ulnar artery by performing the Allen test. Doppler studies, angiography, and pulse oximetry are not necessary prior to ABGs being drawn

A client appears to be breathing faster than during the last assessment. Which of the following interventions should the nurse perform? a) Inquire if there have been any stressful visitors. b) Count the rate of respirations. c) Assess the radial pulse. d) Assist the client to lie down.

b) Count the rate of respirations Rationale: Observing the rate and depth of respiration is an important aspect of a nursing assessment. The normal adult resting respiratory rate is 12 to 18 breaths per minute. Tachypnea is rapid breathing with a rate greater than 24 breaths per minute. An increase in the rate of respirations needs further investigation and must be reported.

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? a) Reduced lighting in the room b) Diagnosis of peripheral vascular disease c) Placement of the probe on an earlobe d) Increased temperature of the room

b) Diagnosis of peripheral vascular disease Rationale: Pulse oximetry is a noninvasive method of monitoring oxygen saturation of hemoglobin. A probe is placed on the fingertip, forehead, earlobe, or bridge of nose. Inaccuracy of results may be from anemia, bright lights, shivering, nail polish, or peripheral vascular disease.

A nurse is concerned that a client may develop postoperative atelectasis. Which nursing diagnosis would be most appropriate if this complication occurs? a) Ineffective airway clearance b) Impaired gas exchange c) Impaired spontaneous ventilation d) Decreased cardiac output

b) Impaired gas exchange Rationale: Airflow is decreased with atelectasis, which is a bronchial obstruction from collapsed lung tissue. If there is an obstruction, there is limited or no gas exchange in this area. Impaired gas exchange is thus the most likely nursing diagnosis with atelectasis.

The nursing instructor is talking with senior nursing students about diagnostic procedures used in respiratory diseases. The instructor discusses thoracentesis, defining it as a procedure performed for diagnostic purposes or to aspirate accumulated excess fluid or air from the pleural space. What would the instructor tell the students purulent fluid indicates? a) Inflammation b) Infection c) Heart failure d) Cancer

b) Infection Rationale: A small amount of fluid lies between the visceral and parietal pleurae. When excess fluid or air accumulates, the physician aspirates it from the pleural space by inserting a needle into the chest wall. This procedure, called thoracentesis, is performed with local anesthesia. Thoracentesis also may be used to obtain a sample of pleural fluid or a biopsy specimen from the pleural wall for diagnostic purposes such as a culture, sensitivity, or microscopic examination. Purulent fluid is the recommended diagnosis for infection. Serous fluid may be associated with cancer, inflammatory conditions, or heart failure.

The nurse auscultates lung sounds that are harsh and cracking, sounding like two pieces of leather being rubbed together. The nurse would be correct in documenting this finding as a) sonorous wheezes b) pleural friction rub c) sibilant wheezes d) crackles

b) Pleural friction rub Rationale: A pleural friction rub is heard secondary to inflammation and loss of lubricating pleural fluid. Crackles are soft, high-pitched, discontinuous popping sounds that occur during inspiration. Sonorous wheezes are deep, low-pitched rumbling sounds heard primarily during expiration. Sibilant wheezes are continuous, musical, high-pitched, whistlelike sounds heard during inspiration and expiration.

A client with a suspected pulmonary disorder undergoes pulmonary function tests. To interpret test results accurately, the nurse must be familiar with the terminology used to describe pulmonary functions. Which term refers to the volume of air inhaled or exhaled during each respiratory cycle? a) Functional residual capacity b) Tidal volume c) Maximal voluntary ventilation d) Vital capacity

b) Tidal volume Rationale: Tidal volume refers to the volume of air inhaled or exhaled during each respiratory cycle when breathing normally. Normal tidal volume ranges from 400 to 700 ml. Vital capacity refers to the total volume of air that can be exhaled during a slow, maximal expiration after maximal inspiration. Functional residual capacity refers to the volume of air remaining in the lungs after a normal expiration. Maximal voluntary ventilation is the greatest volume of air expired in 1 minute with maximal voluntary effort.

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) A catheter in the arm vein b) The pleural surfaces c) A puncture at the radial artery d) The trachea and bronchi

c) A puncture at the radial artery Rationale: ABGs determine the blood's pH, oxygen-carrying capacity, levels of oxygen, CO2, and bicarbonate ion. Blood gas samples are obtained through an arterial puncture at the radial, brachial, or femoral artery. A client also may have an indwelling arterial catheter from which arterial samples are obtained. Blood gas samples are not obtained from the pleural surfaces or trachea and bronchi.

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? a) Son's statement b) Respiratory rate c) Cyanosis d) Crackles

c) Cyanosis Rationale: The client's appearance may give clues to respiratory status. Cyanosis, a bluish coloring of the skin, is a very late indicator of hypoxia. The presence of cyanosis is from decreased unoxygenated hemoglobin. In the presence of a pulmonary condition, cyanosis is assessed by observing the color of the tongue and lips.

While conducting the physical examination during assessment of the respiratory system, which of the following conditions does a nurse assess by inspecting and palpating the trachea? a) Evidence of exudate b) Evidence of muscle weakness c) Deviation from the midline d) Color of the mucous membranes

c) Deviation from the midline Rationale: During the physical examination, the nurse must inspect and gently palpate the trachea to assess for placement and deviation from the midline. The nurse examines the posterior pharynx and tonsils with a tongue blade and light, and notes any evidence of swelling, inflammation, or exudate, as well as changes in color of the mucous membranes. The nurse also examines the anterior, posterior, and lateral chest walls for any evidence of muscle weakness.

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

c) Lungs are clear on auscultation. Rationale: Assessment of lung sounds includes auscultation for airflow through the bronchial tree. The nurse evaluates for fluid or solid obstruction in the lung. When airflow is decreased, as with fluid or secretions, adventitious sounds may be auscultated. Often crackles are heard with fluid in the airways.

A 53-year-old client is seeing the physician today because he has had laryngitis for 2 weeks. After a thorough examination, the doctor orders medications and instructs the client to follow up in 1 week if his voice has not improved. What is the primary function of the larynx? a) Preventing infection b) Facilitating coughing c) Producing sound d) Protecting the lower airway from foreign objects

c) Producing sound Rationale: The larynx, or voice box, is a cartilaginous framework between the pharynx and trachea. Its primary function is to produce sound.

In which position should the patient be placed for a thoracentesis? a) Lateral recumbent b) Prone c) Sitting on the edge of the bed d) Supine

c) Sitting on the edge of the bed Rationale: If possible place the patient upright or sitting on the edge of the bed with the feet supported and arms and head on a padded over-the-bed table. Other positions in which the patient could be placed include straddling a chair with arms and head resting on the back of the chair, or lying on the unaffected side with the head of the bed elevated 30 to 45 degrees if unable to assume a sitting position.

Perfusion refers to blood supply to the lungs, through which the lungs receive nutrients and oxygen. What are the two methods of perfusion? a) The two methods of perfusion are the alveolar and pulmonary circulation. b) The two methods of perfusion are the bronchial and alveolar circulation. c) The two methods of perfusion are the bronchial and pulmonary circulation. d) The two methods of perfusion are the bronchial and capillary circulation.

c) The two methods of perfusion are the bronchial and pulmonary circulation. Rationale: Perfusion refers to blood supply to the lungs, through which the lungs receive nutrients and oxygen. The two methods of perfusion are the bronchial and pulmonary circulation.

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

c) They can be heard during inspiration and expiration. Rationale: Sibilant or hissing or whistling wheezes are continuous musical sounds that can be heard during inspiration and expiration. They result from air passing through narrowed or partially obstructed air passages and are heard in clients with increased secretions. The crackling or grating sounds heard during inspiration or expiration are friction rubs. They occur when the pleural surfaces are inflamed.

Which of the following is a late sign of hypoxia? a) Hypotension b) Restlessness c) Somnolence d) Cyanosis

d) Cyanosis Rationale: Cyanosis is a late sign of hypoxia. Hypoxia may cause restlessness and an initial rise in blood pressure that is followed by hypotension and somnolence.

A patient diagnosed with a pulmonary embolism (PE) would be expected to have which type of ventilation-perfusion? a) Normal b) Silent unit c) Shunt d) Dead space

d) Dead space Rationale: Adequate ventilation but impaired perfusion (as in pulmonary emboli which is a blood clot in pulmonary vessels) is termed increased dead space. Shunting occurs when ventilation is impaired and perfusion is adequate. Absence of ventilation and perfusion is a silent unit.

Austin Holbritter, a six-month-old male, and his elder brother Matthew, a three-year-old male, are being seen in the pediatric clinic where you practice nursing. They are being seen by the physician for their third middle ear infection of this winter season. The mother reports they develop an upper respiratory infection and an ear infection seems quick to follow. What contributes to this event? a) Oropharynx b) Epiglottis c) Genetics d) Eustachian tubes

d) Eustachian tubes Rationale: The nasopharynx contains the adenoids and openings of the eustachian tubes. The eustachian tubes connect the pharynx to the middle ear and are the means by which upper respiratory infections spread to the middle ear.

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

d) No sensation during palpation Rationale: Sinus assessment involves using the thumbs to apply gentle pressure in an upward fashion at the sinuses. Tenderness suggests inflammation. The sinuses can be inspected by transillumination, where a light is passed through the sinuses. If the light fails to penetrate, the cavity contains fluid.

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

d) Orthopnea Rationale: Orthopnea is the inability to breathe easily except when upright. This positioning can mean while in bed and propped with a pillow or sitting in a chair. If a client cannot breathe easily while lying down, there is an element of respiratory distress.

The instructor of the pre-nursing physiology class is explaining respiration to the class. What does the instructor explain is the main function of respiration? a) To move O2 out of the atmospheric air and into the retained air b) To move CO2 out of the atmospheric air and into the expired air c) To exchange atmospheric air between the blood and the cells d) To exchange oxygen and CO2 between the atmospheric air and the blood and between the blood and the cells

d) To exchange oxygen and CO2 between the atmospheric air and the blood and between the blood and the cells Rationale: The main function of the respiratory system is to exchange oxygen and CO2 between the atmospheric air and the blood and between the blood and the cells. This process is called respiration. The purpose of respiration is not to move any gas into the expired air; retained air is simply a distractor for this question; and atmospheric air is not exchanged between the blood and the cells.

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

d) Use of accessory muscles Rationale: The use of accessory muscles for respiration indicates the client is having difficulty breathing. Diaphragmatic and pursed-lip breathing are two controlled breathing techniques that help the client conserve energy.