RESPIRATORY ASSESSMENT CHAPTER 17
What is the difference between sibilant and sonorous wheezes?
Sibilant - Hissing or whistling Sonorous - Full and deep
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?
Sibilant wheezes
Which ventilation-perfusion ratio is exhibited by acute respiratory distress syndrome (ARDS)?
Silent Unit
If the vital capacity of a patient is less than _________________, the patient will be unable to sustain spontaneous ventilation and will require respiratory assistance.
10 mL/kg
Normally, approximately what percentage of the blood pumped by the right ventricle does not perfuse the alveolar capillaries?
2%
What is the systolic blood pressure in the pulmonary artery?
20-30 mmHg
Cyanosis appears when there is at least _____________ of unoxygenated hemoglobin
5 g/dL
What is the diastolic pressure in the pulmonary artery?
5-15 mmHg
Tachypnea is rapid, shallow breathing at a rate of
>24 breaths/min
Fremitus
A palpable vibration of speech felt against the chest wall
A decrease in inspiratory capacity may indicate what type of disease?
A restrictive disease
A nurse interviewing a patient who says they have a dry, irritating cough that is not "bringing anything up" should ask whether they are taking _____________________
ACE Inhibitors
Egophony
Abnormal chance in the tone of voice that is heard when auscultating the lungs.
The nurse assessed a 28-year-old woman who was experiencing dyspnea severe enough to make her seek medical attention. The history revealed no prior cardiac problems and the presence of symptoms for 6 months' duration. On assessment, the nurse noted the presence of both inspiratory and expiratory wheezing. Based on this data, which diagnosis is likely?
Asthma
Perfusion refers to blood supply to the lungs, through which the lungs receive nutrients and oxygen. What are the two methods of perfusion?
Bronchial and Pulmonary Circulation
What sign is often found in chronic hypoxic conditions/infections and congenital heart disease?
Clubbing of the fingers
How do restrictive conditions such as obesity, ascites, and pregnancy affect the expiratory reserve volume (ERV)?
ERV volume is decreased
A client is seen in the emergency room for a case of diabetic acidosis with the presence of Kussmaul respirations. What client condition is associated with the presence of Kussmaul respirations?
Hyperventilation
Hemoptysis
Coughing or spitting up blood from the respiratory tract
Barrel chest is a hallmark sign of what two conditions?
Emphysema and COPD
What structures does the larynx consist of?
Epiglottis, glottis, thyroid cartilage, cricoid cartilage, arytenoid cartilage, and vocal cords
True or False: The nurse can rely on visual inspection of the rate and depth of a patient's respiratory excursions to determine the adequacy of ventilation.
False. Explanation: Respiratory excursions may appear normal or exaggerated due to an increased work of breathing, but the patient may actually be moving only enough air to ventilate the dead space.
Which imaging study will view the thoracic cavity while in motion?
Fluoroscopy
A client with sinus congestion complains of discomfort when the nurse is palpating the supraorbital ridges. What sinus is the client referring?
Frontal Sinus
Cheyne-Stokes is associated with
HF and damage to the respiratory center of the brain
Visceral Pleura
Inner layer that covers the lungs
Which respiratory volume is the maximum volume of air that can be inhaled after a normal exhalation?
Inspiratory Reserve Volume
A patient with metabolic acidosis, renal failure, or diabetic ketoacidosis is likely to experience what breathing pattern?
Kussmal resppirations
What medication should be withhold the day of a CT?
Metformin. This prevents lactic acidosis from developing.
Parietal Pleura
Outer layer of the pleura that lines the thoracic cavity, lateral wall of the mediastinum, diaphragm, and inner aspects of the ribs
What arterial blood gas measurement beset reflects the adequacy of alveolar ventilation?
PaCO2
PO2
Partial Pressure of Oxygen
PaO2
Partial pressure of arterial oxygen
PCO2
Partial pressure of carbon dioxide
Biot's Respiration
Periods of normal breathing, followed by a varying period of apnea
Silent units are seen with ____________________ and ________________
Pneumothorax and severe ARDS
Physiologic Dead Space
Portion of the tracheobronchial tree that does not participate in gas exchange.
Cheyne-Stokes Respiration
Regular cycle where the rate and depth of breathing increase, then decrease until apnea occurs
How may obstructive diseases affect the residual volume (RV)?
Residual volume may be increased as not all the air can be exhaled.
Funnel Chest (Pectus Excavatum) may occur with which two conditions?
Rickets and Marfan Syndrome
Pigeon Chest (Pectus Carinatum) may occur with what 3 conditions?
Rickets, Marfan Syndrome, or Severe Kyphoscoliosis
A client with chronic bronchitis is admitted to the health facility. Auscultation of the lungs reveals low-pitched, rumbling sounds. What breath sound should the nurse document?
Ronchi
Immediate intervention is warranted when what breath sounds is observed?
Stridor
To best visualize the lungs, what teaching should the nurse provide the patient getting a chest x-ray?
Take a deep breath and hold it without discomfort.
What happens to the alveoli as adults age that decreases gas exchange?
The alveolar walls contain fewer capillaries
Compliance
The force required to inflate the lungs
Pectus Carinatum
The sternum protrudes and the ribs are sloped backwards. Also known as pigeon chest.
A nurse is caring for a client who has frequent upper respiratory infections. Which structure is most helpful in protecting against infection?
Tonsils
A nurse is assessing a client's respiratory system. Which alveolar cells secrete surfactant to reduce lung surface tension?
Type II
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? Bronchial, Vesicular, or Bronchovesicular?
Vesicular
Bronchoscopy
Visual examination of the larynx, trachea, and bronchi using an endoscope
Bronchophony
Voice sound that can be heard during auscultation when lung consolidation is present. An abnormal increase in the clarity of transmitted voice sounds.
Whispered Pectoriloquy
Whispered voice sounds heard loudly and clearly when auscultating the lungs
Pink-tinged sputum suggests
a lung tumor
If a contrast agent is required for a CT scan, the nurse should assess the patient for
allergies to iodine or shellfish
Thick and yellow, green, or rust colored sputum is a common sign of
bacterial infection
Biot's respirations are often seen in cases of __________ insult
brain
Cheyne-Stokes respirations are often seen in cases of ___________ insult
cardiac
gradual increase of sputum over time may indicate what condition(s)?
chronic bronchitis or bronchiectasis
Biots Respirations are associated with respiratory depression resulting from
drug overdose and brain injury (typically at the medulla)
Hyperventilation is associated with
exertion, anxiety, and metabolic acidosis
Crackles in general are often caused by
fluid in the airways or alveoli
What densities in the lungs can be seen on a chest x-ray?
fluid, tumors, and foreign bodies
In emphysema, _______________ compliance can be observed
increased
Bradypnea is associated with
increased intracranial pressure, brain injury, and drug overdose
Fine crackles are associated with
interstitial pneumonia and restrictive pulmonary diseases
A Black client with asthma seeks emergency care for acute respiratory distress. Because of this client's dark skin, the nurse should assess for cyanosis by inspecting the
mucous membranes
Coarse crackles are associated with
obstructive pulmonary disease
Kyphoscoliosis may occur with
osteoporosis and other skeletal disorders that affect the thorax
Barrel chest occurs as a result of
overinflation of the lungs
Shunts are often seen with obstruction of the distal airways, such as with
pneumonia, atelectasis, tumor, or a mucus plug
Chest x-rays are contraindicated in
pregnant women
profuse, frothy, pink material expectorated often indicates
pulmonary edema
In absence of both ventilation and perfusion or with limited ventilation and perfusion, a condition known as a _____________________ occurs
silent unit
What factors determine lung compliance?
surface tension of the alveoli, connective tissue and water content, and compliance of the thoracic cavity
The term "Adams Apple" is used to refer to a laryngeal prominence called the
thyroid cartilage
thin, mucoid sputum is a common sign of
viral bronchitis
Tidal Volume
volume of air inhaled and exhaled with each breath