PrepU: Ch 20 Assessment of Respiratory Function

The nurse is interviewing a patient who says he has a dry, irritating cough that is not "bringing anything up." What medication should the nurse question the patient about taking?

Angiotensin converting enzyme (ACE) inhibitors

The nurse auscultated a patient's middle lobe of the lungs for abnormal breath sounds. To do this, the nurse placed the stethoscope on the:

Anterior surface of the right side of the chest, between the fourth and fifth rib.

A client arrives in the emergency department reporting shortness of breath. She has 3+ pitting edema below the knees, a respiratory rate of 36 breaths per minute, and heaving respirations. The nurse auscultates the client's lungs to reveal coarse, moist, high-pitched, and non-continuous sounds that do not clear with coughing. The nurse will document these sounds as which type?

Crackles

Bradypnea is associated with which condition?

Increased intercranial pressure

What is the difference between respiration and ventilation?

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

In relation to the structure of the larynx, the cricoid cartilage is

the only complete cartilaginous ring in the larynx.

The term for the volume of air inhaled and exhaled with each breath is

tidal volume

A thorascentesis is performed to obtain a sample of pleural fluid or a biopsy specimen from the pleural wall for diagnostic purposes. What does bloody fluid results indicate?

trauma

A client has suspected fluid accumulation in the pleural space of the lungs and is scheduled for a thoracentesis. The nurse will implement which of the following for this procedure? Select all that apply.

Educate the client about the need to cleanse the thoracic area. Apply pressure to the puncture site after the procedure. Complete a respiratory assessment after the procedure.

During a preadmission assessment, for what diagnosis would the nurse expect to find decreased tactile fremitus and hyperresonant percussion sounds?

Emphysema

High or increased compliance occurs in which condition?

Emphysema

A patient with sinus congestion points to a location on the inside of his eye as the area of pain. The nurse documents that the patient is complaining of pain in which sinus?

Ethmoid

The Family Nurse Practitioner is performing a physical examination of a client. The Nurse Practitioner examines the client's anterior, posterior, and lateral chest walls. What is the Nurse Practitioner assessing?

Evidence of muscle weakness

You are assessing the respiratory system of a client just admitted to your unit. What do you know to assess in addition to the physical and functional issues related to breathing?

How these issues affect the client's quality of life

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

An client is described as having pectus carinatum. What would be the physical manifestation of this condition?

The sternum protrudes and the ribs are sloped backward. (aka pigeon chested)

Perfusion refers to blood supply to the lungs, through which the lungs receive nutrients and oxygen. What are the two methods of perfusion?

The two methods of perfusion are the bronchial and pulmonary circulation.

A client will be undergoing a bronchoscopy. Which statement shows that the client understands the procedure?

"It sounds like the different drugs will make this much easier to stand."

Inspection of a patient's skin color is part of the assessment of the integumentary system. Cyanosis, which is a late indicator of hypoxia, is present when the unoxygenated hemoglobin level is:

5g/dL

A nurse understands that a safe but low level of oxygen saturation provides for adequate tissue saturation while allowing no reserve for situations that threaten ventilation. What is a safe but low oxygen saturation level for a patient?

95%

A nurse would question the accuracy of a pulse oximetry evaluation in which of the following conditions?

A client experiencing hypothermia

A client with exacerbation of chronic obstructive pulmonary disease (COPD) is scheduled for a thoracentesis. Which nursing intervention would be appropriate for client saftey?

Administering a prn cough suppressant

Which is a true statement regarding air pressure variances?

Air is drawn through the trachea and bronchi into the alveoli during inspiration.

The nurse is caring for clients on the neurological unit. Which triad of neurological mechanisms does the nurse identify as most responsible when there is abnormality in ventilation control?

Aortic arch, pons, and CO2 receptor sites

The nurse is caring for a client reporting chest discomfort. The client's diagnosis at admission is left lower lobe pneumonia. Which strategy will the nurse instruct the client to use to help alleviate the discomfort?

Assume a left side-lying position while in bed

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

Bradypnea

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

Clubbing of the fingers

The nurse auscultates crackles in a patient with a respiratory disorder. With what disorder would crackles be commonly heard?

Collapsed alveoli

Which ventilation-perfusion ratio is exhibited in a client diagnosed with a pulmonary embolus?

Dead space

Which is an age-related change associated with the respiratory system?

Decreased size of the airway

A nurse is obtaining a health history from a client who reports hemoptysis for the past 2 months. The client reports occasional dyspnea. Which imaging study, ordered by the physician, will view the thoracic cavity while in motion?

Fluoroscopy

A physician wants a study of diaphragmatic motion because of suspected pathology. What does the nurse anticipate that the physician will most likely order?

Fluoroscopy

A patient is seen in the emergency room for a severe case of diabetic acidosis. The respiratory note indicates the presence of Kussmaul's respirations. The nurse knows that this diagnosis is associated with which of the following?

Hyperventilation

On arrival at the intensive care unit, a critically ill client suffers respiratory arrest and is placed on mechanical ventilation. The physician orders pulse oximetry to monitor the client's arterial oxygen saturation (SaO2) noninvasively. Which vital sign abnormality may alter pulse oximetry values?

Hypotension

A client arrived in the emergency department with a sharp object penetrating the diaphragm. When planning nursing care, which nursing diagnosis would the nurse identify as a priority?

Impaired Gas Exchange

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

Which of the following is an age-related change associated with the lung?

Increased thickness of the alveolar membranes

A pediatrician diagnosed a child with swollen and inflamed adenoids. The nurse practitioner confirmed the diagnosis by:

Inspecting the roof of the nasopharynx.

Which respiratory volume is the maximum volume of air that can be inhaled after maximal expiration?

Inspiratory reserve volume

A new nurse auscultates adventitious breath sounds but is not sure what to document and confers with an experienced nurse. This experienced nurse documents a pleural friction rub. Which of the following did the experienced nurse do during her assessment to identify the rub?

Instructed the client to hold the breath

What happens to the diaphragm during inspiration?

It contracts and flattens.

During a pulmonary assessment, the nurse observes the chest for configuration. She identifies the findings as normal. Which of the following would be consistent with normal assessment?

Lateral diameter greater than anteroposterior diameter

A client presents to the ED reporting severe coughing episodes. The client states that "the episodes are more intense at night." The nurse should suspect which of the following conditions based on the client's primary report?

Left-sided heart failure

The nurse is caring for a client in the immediate post-thoracentesis period. In which position is the client placed?

Lying on the unaffected side

The student nurse is learning breath sounds while listening to a client in the physician's office. An experienced nurse is assisting and notes air movement over the trachea to the upper lungs. The air movement is noted equally on inspiration as expiration. Which breath sounds would the nurse document?

Normal bronchovesicular sounds

A client is receiving moderate sedation while undergoing bronchoscopy. Which assessment finding should the nurse attend to immediately?

Oxygen saturation of 90%

The nurse is caring for a client with suspected lung cancer. Which imaging study is more accurate than computed tomography in detecting malignancies?

PET

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 young adult visited a clinic because he was injured during a softball game. He told the nurse that the ball struck him in his "Adam's apple." To assess the initial impact of injury, the nurse:

Palpates the thyroid cartilage.

During a preadmission assessment, the nurse finds increased tactile fremitus. She knows this sign is consistent with which of the following diagnoses?

Pneumonia

A patient exhibited signs of an altered ventilation-perfusion ratio. The nurse is aware that adequate ventilation but impaired perfusion exists when the patient has which of the following conditions?

Pulmonary Embolism

A student nurse is working with a client who is diagnosed with head trauma. The nurse has documented Cheyne-Stokes respirations. The student would expect to see which of the following?

Regular breathing where the rate and depth increase, then decrease

An 18-month-old child is brought to the Emergency Department by parents who explain that their child swallowed a watch battery. Radiologic studies show that the battery is in the lungs. Which area of lung is the battery most likely to be in?

Right upper lung

The nurse is admitting a client who just had a bronchoscopy. Which assessment should be the nurse's priority?

Swallow reflex

The nurse is instructing the patient on the collection of a sputum specimen. What should be included in the instructions? (Select all that apply.)

Take a few deep breaths before coughing. Use diaphragmatic contractions to aid in the expulsion of sputum. Initially, clear the nose and throat.

What determines the amount of CO2 in the blood for the lungs to excrete?

The amount of hydrogen ions in the blood

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.

Which homeostatic mechanism would the body of a critically ill client use to maintain normal pH?

The lungs eliminate carbonic acid by blowing off more CO2

You are studying for a physiology test about the respiratory system. What should you know about central chemoreceptors in the medulla?

They respond to changes in CO2 levels and hydrogen ion concentrations (pH) in the cerebrospinal fluid.

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

The nurse is caring for a client with a decrease in airway diameter causing airway resistance. The client experiences coughing and mucus production. Upon lung assessment, which adventitious breath sounds are anticipated?

Wheezes

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?

Wheezes

A client is chronically short of breath and yet has normal lung ventilation, clear lungs, and an arterial oxygen saturation SaO2 of 96% or better. The client most likely has:

a possible hematologic problem.

A client is being seen in the pediatric clinic for a middle ear infection. The client's mother reports that when the client develops an upper respiratory infection, an ear infection seems quick to follow. What contributes to this event?

eustachian tubes

The nurse auscultates the lung sounds of a client during a routine assessment. The sounds produced are harsh and cracking, sounding like two pieces of leather being rubbed together. The nurse would be correct in documenting this finding as

pleural friction rub.

Pink, frothy sputum may be an indication of

pulmonary edema

The nurse is assessing a patient in respiratory failure. What finding is a late indicator of hypoxia?

Cyanosis

The nurse is performing an assessment of a patient who arrived in the emergency department with a barbiturate overdose. The respirations are normal for 3 to 4 breaths followed by a 60-second period of apnea. How does the nurse document the respirations?

Biot's respirations

The nurse is caring for a critically ill client in the ICU. The nurse documents the client's respiratory rate as bradypnea. The nurse recognizes that bradypnea is associated with which condition?

Increased intracranial pressure