PrepU: Chapter 19-Lung Assessment, Med Surg 2. Chapter 21, CC Ch. 21, Ch 21 Respiratory Care Modalities, PrepU Resp AH, MedSurg Chapter 21 Respiratory Care Modalities, Ch 21 - Respiratory Care Modalities, Ex. 4-Ch. 21 (Med Surg) Resp. Care Modalities

When performing endotracheal suctioning, the nurse applies suctioning while withdrawing and gently rotating the catheter 360 degrees for which of the following time periods?

10 to 15 seconds

Which of the following ranges of water pressure identifies the amount of pressure within the endotracheal tube cuff that is believed to prevent both injury and aspiration?

15 to 20 mm Hg

A client has a tracheostomy but doesn't require continuous mechanical ventilation. When weaning the client from the tracheostomy tube, the nurse initially should plug the opening in the tube for:

5 to 20 minutes.

A nurse is receiving report from the night shift about four clients. Which client would the nurse see first?

A 64-year-old man with COPD who is short of breath and has a respiratory rate of 32 breaths/min.

The nurse is preparing to auscultate the posterior thorax of an adult female client. The nurse should

Ask the client to breathe deeply through her nose.

A client in the intensive care unit has a tracheostomy with humidified oxygen being instilled through it. The client is expectorating thick yellow mucus through the tracheostomy tube frequently. The nurse

Assesses the client's tracheostomy and lung sounds every 15 minutes

A nurse provides care for a client receiving oxygen from a nonrebreather mask. Which nursing intervention has the highest priority?

Assessing the client's respiratory status, orientation, and skin color

Auscultation of a 23-year-old client's lungs reveals an audible wheeze. What pathological phenomenon underlies wheezing?

Narrowing or partial obstruction of an airway passage.

A nurse observes a client sitting in the tripod position. What is an appropriate action by the nurse in response to this observation?

Observe for the use of accessory muscles.

During the lung assessment for a client with pneumonia, the nurse auscultates low-pitched, bubbling, moist sounds that persist from early inspiration to early expiration. How should the nurse document these sounds?

Coarse crackles.

A client is on a positive-pressure ventilator with a synchronized intermittent mandatory ventilation (SIMV) setting. The ventilator is set for 8 breaths per minute. The client is taking 6 breaths per minute independently. The nurse

Continues assessing the client's respiratory status frequently

A client is coughing copious amounts of purulent mucous. What disease condition is related to this finding?

Lung abscess.

A client with chronic obstructive pulmonary disease (COPD) is intubated and placed on continuous mechanical ventilation. Which equipment is most important for the nurse to keep at this client's bedside?

Manual resuscitation bag

The clavicles extend from the acromion of the scapula to the part of the sternum termed the

Manubrium.

For a client who has a chest tube connected to a closed water-seal drainage system, the nurse should include which action in the care plan?

Measuring and documenting the drainage in the collection chamber

An elderly client reports a feeling of dyspnea with normal activities of daily living. What is an appropriate action by the nurse?

Observe the client's respiratory rate and pattern.

When auscultating the lungs, the nurse listens over symmetrical lung fields for which of the following?

One deep inspiration and expiration through the open mouth.

A client who is undergoing thoracic surgery has a nursing diagnosis of "Impaired gas exchange related to lung impairment and surgery" on the nursing care plan. Which of the following nursing interventions would be appropriately aligned with this nursing diagnosis? Select all that apply.

Monitor pulmonary status as directed and needed. Regularly assess the client's vital signs every 2 to 4 hours. Encourage deep breathing exercises.

How should a nurse position a client to accurately auscultate the right middle lobe of the lung?

Move the right arm away from the body.

A nurse is caring for a client who recently underwent a tracheostomy. The first priority when caring for a client with a tracheostomy is:

keeping his airway patent.

Which of the following occurs in respiratory distress?

Skin between the ribs moves inward with inspiration.

When assessing whispered pectoriloquy, the nurse would instruct a client to do which of the following?

Softly repeat the words "one-two-three".

A nurse observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude?

The system has an air leak.

Which observation confirms to the nurse that the client is experiencing a normal inspiration?

The thoracic cavity enlarges.

A client has sustained a brainstem injury. Which of the following would the nurse need to keep in mind about this client's respiratory effort?

There is a loss of involuntary respiratory control.

An adult client visits the clinic and tells the nurse that he has been "spitting up rust-colored sputum." The nurse should refer the client to the physician for possible

Tuberculosis.

Which finding during an assessment of a client should alert the nurse to the presence of a persistent atelectasis?

Unequal expansion of the chest.

A client presents to the health care clinic and reports a recent onset of a persistent cough. The client denies any shortness of breath, change in activity level, or other findings of an acute upper respiratory tract illness. What question by the nurse is most appropriate to further assess the cause for the cough?

"Are you taking any medications on a regular basis?"

The nurse is preparing to perform chest physiotherapy (CPT) on a patient. Which of the following patient statements would indicate the procedure is contraindicated.

"I just finished eating my lunch, I'm ready for my CPT now."

During a health history of the respiratory system, a patient reports experiencing a cough for several months. Which questions would the nurse ask for more information about the duration of this symptom? (Select all that apply.)

-"Does this occur at a particular time of day?" -"Is it continuous or intermittent?" -"Does it occur at rest or with exercise?" -"Does it wake you at night?"

The thoracic cavity contains which of the following organs? Select all that apply.

-Heart. -Most of the esophagus. -Lungs.

A young toddler is brought to the emergency room by his parents. The mother states that the child was playing on the floor with toys and suddenly began to wheeze. The mother reports no recent illnesses. The nurse suspects that the most likely cause of the wheezing is

A foreign body obstruction.

A client is on a ventilator. Alarms are sounding, indicating an increase in peak airway pressure. The nurse assesses first for

A kink in the ventilator tubing

The nurse is caring for a patient following a wedge resection. While the nurse is assessing the patient's chest tube drainage system, constant bubbling is noted in the water seal chamber. This finding indicates which of the following problems?

Air leak

A hospitalized client experiences respiratory distress. The nurse should include which most appropriate client outcome in the plan of care?

Airway patent, breathing quiet, denies dyspnea.

While inspecting the thorax, the nurse views it from posterior and lateral positions to assess which of the following?

Anteroposterior to lateral diameter.

The apex of each lung is located at the

Area slightly above the clavicle.

A 21-year-old college senior presents to the clinic reporting shortness of breath and a nonproductive nocturnal cough. She states she used to feel this way only with extreme exercise, but lately she has felt this way continuously. She denies any other upper respiratory, gastrointestinal, and urinary symptoms and says she has no chest pain. Her past medical history is significant only for seasonal allergies, for which she takes a nasal steroid spray; she takes no other medications. She has had no surgeries. Her mother has allergies and eczema; her father has high blood pressure. She is an only child. She denies smoking and illegal drug use but drinks three to four alcoholic beverages per weekend. She is a junior in finance at a local university and has recently started a job as a bartender in town. On examination she is in no acute distress. Temperature is 98.6, blood pressure is 120/80, pulse is 80, and respirations are 20. Head, eyes, ears, nose, and throat examinations are essentially normal. Inspection of her anterior and posterior chest shows no abnormalities. On auscultation of her chest, there is decreased air movement and a high-pitched whistling on expiration in all lobes. Percussion reveals resonant lungs. Which disorder of the thorax or lung does this presentation best describe?

Asthma.

For a client with an endotracheal (ET) tube, which nursing action is the most important?

Auscultating the lungs for bilateral breath sounds

A nurse prepares to perform postural drainage. How should the nurse ascertain the best position to facilitate clearing the lungs?

Auscultation

Before weaning a client from a ventilator, which assessment parameter is the most important for the nurse to obtain?

Baseline arterial blood gas (ABG) levels

The nurse is preparing to percuss a patient's anterior chest area. Which approach will the nurse use for this assessment?

Begin above the right clavicle and percuss each section comparing the right chest with the left chest.

Which of the following is an adverse reaction that would require termination of the weaning process from the ventilator?

Blood pressure increase of 20 mm Hg

A nurse performs a respiratory assessment on a client and notes the respiratory rate to be 10 breaths per minute. The nurse knows the proper term for this rate is what?

Bradypnea.

Which of the following statements relating to assessment of the lungs and thorax is most accurate?

Bronchitis is characterized by excess mucus production and chronic cough.

A nurse is assigned to care for a client with a tracheostomy tube. How can the nurse communicate with this client?

By supplying a magic slate or similar device

The nurse is performing the technique shown. What is the nurse assessing?

Chest expansion.

The nurse assesses an adult client and observes that the client's breathing pattern is very labored and noisy, with occasional coughing. The nurse should refer the client to a physician for possible

Chronic bronchitis.

During the lung assessment for a client with pneumonia, the nurse auscultates low-pitched bubbling, moist sounds that persists from early inspiration to early expiration. How should the nurse document these sounds?

Coarse crackles.

A 62-year-old construction worker presents to the clinic reporting almost a chronic cough and occasional shortness of breath that have lasted for almost 1 year. Although symptoms have occasionally worsened with a cold, they have stayed about the same. The cough has occasional mucus drainage but never any blood. He denies any chest pain. He has had no weight gain, weight loss, fever, or night sweats. His past medical history is significant for high blood pressure and arthritis. He has smoked two packs a day for the past 45 years. He drinks occasionally but denies any illegal drug use. He is married with two children. He denies any foreign travel. His father died of a heart attack and his mother died of Alzheimer's disease. Examination reveals a man looking slightly older than his stated age. His blood pressure is 130/80 and his pulse is 88. He is breathing comfortably with respirations of 12. His head, eyes, ears, nose, and throat examinations are unremarkable. His cardiac examination is normal. On examination of his chest, the diameter seems enlarged. Breath sounds are decreased throughout all lobes. Rhonchi are heard over all lung fields. There is no area of dullness and no increased or decreased fremitus. What thorax or lung disorder is most likely causing his symptoms?

Chronic obstructive pulmonary disease (COPD).

Upon entering the examination room, a nurse observes that the client is leaning forward with arms supporting body weight. The nurse would most likely suspect which of the following?

Chronic obstructive pulmonary disease.

Upon inspection of a client's chest, a nurse observes an increase in the anterior posterior diameter. The nurse recognizes this as a finding in which disease process?

Chronic obstructive pulmonary disease.

Upon inspection of a client's chest, a nurse observes an increase in the ratio of anteroposterior to transverse diameter. The nurse recognizes this as a finding in which disease process?

Chronic obstructive pulmonary disease.

A nurse is auscultating a client's chest for breath sounds. The nurse recognizes that which of the following is the strongest stimulus to breathe?

Hypercapnia.

The nurse has assessed the respiratory pattern of an adult client. The nurse determines that the client is exhibiting Kussmaul respirations with hyperventilation. The nurse should contact the client's physician because this type of respiratory pattern usually indicates

Diabetic ketoacidosis.

Which of the following muscles is primarily responsible for thoracic cavity enlargement?

Diaphragm.

The nurse percusses the lungs of a patient with pneumonia. What percussion note would the nurse expect to document?

Dullness.

What replaces resonance when fluid or solid tissue replaces air-containing lung or occupies the pleural space?

Dullness.

A patient is being educated in the use of incentive spirometry prior to having a surgical procedure. What should the nurse be sure to include in the education?

Encourage the patient to take approximately 10 breaths per hour, while awake.

A client comes to the clinic and states, "I have a bad cold and am having trouble breathing." The nurse checks the client's breath sounds and hears bilateral fine crackles at the base. Of what is this finding indicative?

Fluid in the alveoli.

Which characteristic feature of the sternum should the nurse observe in a client with the diagnosis of pectus carinatum?

Forward protrusion.

A nurse asks a client to say "ninety-nine" as the nurse palpates the posterior thorax. The nurse is assessing which of the following?

Fremitus.

What would the nurse expect to hear when auscultating the lungs of a client with pleuritis?

Friction rub.

A grandmother brings her 13-year-old grandson for evaluation. She noticed last week when he took off his shirt that his breastbone seemed collapsed. He seems embarrassed and says that it has been that way for awhile. He states he has no symptoms from it and that he just tries not to take off his shirt in front of anyone. He denies any shortness of breath, chest pain, or lightheadedness on exertion. His past medical history is unremarkable. He is in sixth grade and just moved in with his grandmother after his father was transferred for a work contract. His mother died several years ago in a car accident. He states that he does not smoke and has never touched alcohol. Examination shows a teenage boy appearing his stated age. Visual examination of his chest reveals that the lower portion of the sternum is depressed. Auscultation of the lungs and heart is unremarkable. What disorder of the thorax best describes these findings?

Funnel chest (pectus excavatum).

The nurse is reviewing the client's health history and notes he has pectus excavatum. The nurse would assess the client for what?

Funnel chest.

During a health history, a client tells the nurse that "I cannot breathe well" at night when the client is lying down. The client also has trouble sleeping because of waking up with trouble breathing. The nurse would assess this client further for which of the following?

Heart failure.

A client has a history of emphysema. The nurse percusses the chest, expecting to find which of the following?

Hyperresonance.

A nurse assesses the respiration pattern on a client who arrives in the emergency department due to an overdose of narcotics. The nurse notes the respirations are decreased in rate and depth, and have an irregular pattern. How should the nurse document this finding?

Hypoventilation.

A home health nurse is visiting a home care client with advanced lung cancer. Upon assessing the client, the nurse discovers wheezing, bradycardia, and a respiratory rate of 10 breaths/minute. These signs are associated with which condition?

Hypoxia

A nurse is caring for a client after a thoracotomy for a lung mass. Which nursing diagnosis should be the first priority?

Impaired gas exchange

A nurse auscultates a client's lungs and hears fine crackles. What is an appropriate action by the nurse?

Instruct the client to cough forcefully.

The nurse is assisting a client with postural drainage. Which of the following demonstrates correct implementation of this technique?

Instruct the client to remain in each position of the postural drainage sequence for 10 to 15 minutes.

A client suffers acute respiratory distress syndrome as a consequence of shock. The client's condition deteriorates rapidly, and endotracheal (ET) intubation and mechanical ventilation are initiated. When the high-pressure alarm on the mechanical ventilator sounds, the nurse starts to check for the cause. Which condition triggers the high-pressure alarm?

Kinking of the ventilator tubing

A client who just underwent hip replacement surgery reports pain at a 10 on a scale of 0 to 10 and receives 4 mg of morphine. A nurse on the orthopedic unit enters the client's room and finds that the client has a respiratory rate of 7 breaths/min. The client is groggy and hard to arouse. What could be contributing to the client's findings?

Opiates, which may cause hypoventilation.

Identify the location where vesicular, bronchovesicular, bronchial, and tracheal lung sounds are heard (in that order).

Over most of the both lungs. Between the scapulae. Over the manubrium. Over the trachea in the neck.

Which of the following would be best for a nurse to use when assessing for fremitus in a client?

Palmar base (ulnar surface).

While performing an assessment of a client who sustained a chest injury, which physical examination technique should the nurse use to elicit crepitus?

Palpation.

A client is receiving supplemental oxygen. When determining the effectiveness of oxygen therapy, which arterial blood gas value is most important?

Partial pressure of arterial oxygen (PaO2)

A triage nurse is working in the emergency department of a busy hospital. Four patients have recently been admitted. Patient A has an arrhythmia diagnosed as atrial fibrillation; Patient B is in chronic congestive heart failure; Patient C is assessed and found to have a probable pulmonary embolism; Patient D complains of chest pain relieved by nitroglycerin and rest. Which patient would be the nurse's highest priority?

Patient C.

Which action by a nurse demonstrates proper technique for assessment of chest expansion?

Place both hands on the posterior chest at T9, press thumbs together, and then ask client to take a deep breath.

A client reports sharp and stabbing chest pain that worsens with deep breathing and coughing. A cardiac cause to this pain is ruled out. The description of the pain is consistent with what respiratory condition?

Pleurisy.

A client from a severe motor vehicle accident arrives in the emergency department. The nurse observes irregular respirations of varying depth and rate followed by periods of apnea. Which of the following would the nurse suspect?

Severe brain damage.

A 47-year-old receptionist comes to the office with fever, shortness of breath, and a productive cough with golden sputum. She says she had a cold last week and her symptoms have only worsened despite using over-the-counter cold remedies. She denies any weight gain, weight loss, or cardiac or gastrointestinal symptoms. Her past medical history includes type 2 diabetes for 5 years and high cholesterol level. She takes an oral medication for both diseases. She has had no surgeries. She denies tobacco, alcohol, or drug use. Her mother has diabetes and high blood pressure. Her father passed away from colon cancer. Examination reveals a middle-aged woman appearing her stated age. She looks ill and her temperature is elevated at 101 degrees Farenheit. Her blood pressure and pulse are unremarkable. Her head, eyes, ears, nose, and throat examination are unremarkable except for edema of the nasal turbinates. On auscultation she has decreased air movement and coarse crackles are heard over the left lower lobe. There is dullness on percussion, increased fremitus during palpation, and egophony and whispered pectoriloquy on auscultation. What disorder of the thorax or lung best describes her symptoms?

Pneumonia.

While assessing an adult client's lungs during the postoperative period, the nurse detects coarse crackles. The nurse should refer the client to a physician for possible

Pneumonia.

The nurse is teaching the client in respiratory distress ways to prolong exhalation to improve respiratory status. The nurse tells the client to

Purse the lips when exhaling air from the lungs.

While assessing the thoracic area of an adult client, the nurse plans to auscultate for voice sounds. To assess bronchophony, the nurse should ask the client to

Repeat the phrase "ninety-nine."

When percussing the posterior lung fields, which of the following findings is expected?

Resonance over all lung fields.

The spinous process termed the vertebra prominens is in which cervical vertebra?

Seventh.

A client is admitted to the health care facility with a diagnosis of left lower lobe pneumonia. What change in egophony should the nurse expect to find in the left lower lobe?

Sound is louder and sounds like "A".

What is the best guide to make vertical locations on the chest?

Sternal angle.

When preparing to examine a client's thoracic cage, the nurse would locate which landmark as most helpful in determining where to start?

Sternal angle.

A high-pitched crowing sound from the upper airway results from tracheal or laryngeal spasm and is called what?

Stridor.

A client with COPD has been receiving oxygen therapy for an extended period. What symptoms would be indicators that the client is experiencing oxygen toxicity? Select all that apply.

Substernal pain Dyspnea Fatigue

The nurse is assisting a physician with an endotracheal intubation for a client in respiratory failure. It is most important for the nurse to assess for:

Symmetry of the client's chest expansion

The staff educator from the hospital's respiratory unit is providing a public educational event. The educator is talking about health promotion activities for people with respiratory diseases or those who are at high risk for respiratory complications. What would the educator include in the presentation?

Teaching strategies to reduce complications of existing diagnoses.

The nurse suctions a patient through the endotracheal tube for 20 seconds and observes dysrhythmias on the monitor. What does the nurse determine is occurring with the patient?

The patient is hypoxic from suctioning.

Which type of ventilator has a present volume of air to be delivered with each inspiration?

Volume-controlled

After lobectomy for lung cancer, a client receives a chest tube connected to a disposable chest drainage system. The nurse observes that the drainage system is functioning correctly when she notes tidal movements or fluctuations in which compartment of the system as the client breathes?

Water-seal chamber