Uprep ch. 20
You are caring for a client admitted with chronic bronchitis. The client is having difficulty breathing, and the family asks you what causes this difficulty. What would be your best response?
"Conditions such as chronic bronchitis cause thickening of the bronchial mucosa so it makes it harder to breathe."
The nurse is instructing the client on the normal sensations, which can occur when contrast medium is infused during pulmonary angiography. Which statement, made by the client, demonstrates an understanding?
"I will feel warm and an urge to cough." Explanation: During a pulmonary angiography a contrast medium is injected into the femoral artery. When the medium is infused, the client will feel a sense of warm and flushed with an urge to cough. The client will feel a pressure when the catheter is inserted. The client does not typically feel light-headed or nauseated during the procedure
cyanosis
-assessed by observing the color of the tongue and lips. -a very late indicator of hypoxia.
The nurse is instructing the patient on the collection of a sputum specimen. What should be included in the instructions?
-initially, clear the nose and throat. -take a few deep breaths before coughing -use diaphragmatic contractions to aid in the expulsion of sputum
Inspiratory reserve volume is normally
3000 mL
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% Explanation: With a normal value for the partial pressure of oxygen (PaO2) (80 to 100 mm Hg) and oxygen saturation (SaO2) (95% to 98%), there is a 15% margin of excess oxygen available to the tissues. With a normal hemoglobin level of 15 mg/dL and a PaO2 level of 40 mm Hg (SaO2 75%), there is adequate oxygen available for the tissues but no reserve for physiologic stresses that increase tissue oxygen demand.
A nurse would question the accuracy of a pulse oximetry evaluation in which of the following conditions?
A client experiencing hypothermia Pulse oximetry is a noninvasive method of continuously monitoring the oxygen saturation of hemoglobin. The reading is referred to as SpO2. A probe or sensor is attached to the fingertip, forehead, earlobe, or bridge of the nose. Values less than 85% indicate that the tissues are not receiving enough oxygen. SpO2 values obtained by pulse oximetry are unreliable in states of low perfusion such as hypothermia.
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?
Absent distal pulses Explanation: 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.
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 Explanation: A thoracentesis is performed to remove fluid and air from the pleural cavity and to aspirate pleural fluid for analysis, pleural biospy, or instillation of medication into the pleural space. The client is placed in an upright position with adequate supports for comfort. The nurse will encourage the client to refrain from coughing. Any sudden and unexpected movement, such as coughing, can traumatize the visceral pleura and lung. Clients experiencing exacerbation of COPD often have a productive cough; therefore, administration of a prn cough medication would be helpful to suppress any potential coughing during the procedure.
A nurse is concerned that a client may develop postoperative atelectasis. Which nursing diagnosis would be most appropriate if this complication occurs?
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.
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?
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.
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 of the following diagnoses is likely?
Asthma Explanation: The presence of both inspiratory and expiratory wheezing usually signifies asthma if the individual does not have heart failure. Sudden dyspnea is an indicator of the other choices.
barrel chest is associated with
COPD and Emphysema
What finding by the nurse may indicate that the patient has chronic hypoxia?
Clubbing of the fingers Explanation: Clubbing of the fingers is a change in the normal nail bed. It appears as sponginess of the nail bed and loss of the nail bed angle (Fig. 20-6). It is a sign of lung disease that is found in patients with chronic hypoxic conditions, chronic lung infections, or malignancies of the lung (Bickley, 2009). The other signs listed may represent only a temporary hypoxia.
What finding by the nurse may indicate that the patient has chronic hypoxia?
Clubbing of the fingers is a change in the normal nail bed. It appears as sponginess of the nail bed and loss of the nail bed angle. It is a sign of lung disease that is found in patients with chronic hypoxic conditions, chronic lung infections, or malignancies of the lung. The other signs listed may represent only a temporary hypoxia.
The nurse is assessing a patient in respiratory failure. What finding is a late indicator of hypoxia?
Cyanosis Explanation: Cyanosis, a bluish coloring of the skin, is a very late indicator of hypoxia. The presence or absence of cyanosis is determined by the amount of unoxygenated hemoglobin in the blood. Cyanosis appears when there is at least 5 g/dL of unoxygenated hemoglobin.
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?
Diagnosis of peripheral vascular disease Explanation: 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.
Which of the following clinical manifestations should a nurse monitor for during a pulmonary angiography, which indicates an allergic reaction to the contrast medium?
Difficulty in breathing
A nurse is preparing a client for bronchoscopy. Which instruction should the nurse give to the client?
Don't eat. 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 client arrives at the physician's office stating dyspnea; a productive cough for thick, green sputum; respirations of 28 breaths/minute, and a temperature of 102.8° F. The nurse auscultates the lung fields, which reveal poor air exchange in the right middle lobe. The nurse suspects a right middle lobe pneumonia. To be consistent with this anticipated diagnosis, which sound, heard over the chest wall when percussing, is anticipated?
Dull Explanation: A dull percussed sound, heard over the chest wall, is indicative of little or no air movement in that area of the lung. Lung consolidation such as in pneumonia or fluid accumulation produces the dull sound. A tympanic sound is a high-pitched sound commonly heard over the stomach or bowel. A resonant sound is noted over normal lung tissue. A hyper resonant sound is an abnormal lower pitched sound that occurs when free air exists in disease processes such as pneumothorax.
The nurse receives an order to obtain a sputum sample from a client with hemoptysis. When advising the client of the physician's order, the client states not being able to produce sputum. Which suggestion, offered by the nurse, is helpful in producing the sputum sample?
Explanation: Taking deep breaths moves air around the sputum and coughing forcefully moves the sputum up the respiratory tract. Once in the pharynx, the sputum can be expectorated into a specimen container. Producing a gag reflex elicits stomach contents and not respiratory sputum. Dilute and thinned secretions are not helpful in aiding expectoration. A sputum culture is not a component of oral secretions.
A patient with sinus congestion complains of discomfort when the nurse is palpating the supraorbital ridges. The nurse knows that the patient is referring to which sinus?
Frontal Explanation: Next, the nurse may palpate the frontal and maxillary sinuses for tenderness (Fig. 20-7). Using the thumbs, the nurse applies gentle pressure in an upward fashion at the supraorbital ridges (frontal sinuses) and in the cheek area adjacent to the nose (maxillary sinuses). Tenderness in either area suggests inflammation.
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. Assessment of the respiratory system includes obtaining information about physical and functional issues related to breathing. It also means clarifying how these issues may affect the client's quality of life.
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 Explanation: 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.
Which respiratory volume is the maximum volume of air that can be inhaled after maximal expiration?
Inspiratory reserve volume
A patient diagnosed with diabetic ketoacidosis would be expected to have which type of respiratory pattern?
Kussmaul respirations
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?
Lungs are clear on auscultation. Explanation: 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 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?
MRI can view soft tissues and can help stage cancers. Explanation: 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.
A client is receiving moderate sedation while undergoing bronchoscopy. Which assessment finding should the nurse attend to immediately?
Oxygen saturation of 90% Explanation: The nurse should respond immediately to an oxygen saturation (SaO2) of 90%. Normal SaO2 ranges from 95% to 100%. Therefore, an SaO2 of 90% indicates inadequate oxygenation, an adverse effect of moderate sedation. The nurse should respond by attempting to arouse the client, assisting the client with deep breathing, and administering a higher dose of oxygen. Cough and gag reflexes are typically absent after administration of anesthetics required for bronchoscopy, and they usually return about 2 hours after the procedure. Blood-tinged secretions are common for several hours after bronchoscopy, especially if a biopsy was obtained. A respiratory rate of 13 breaths/minute is within normal limits.
A patient comes to the emergency department complaining of a knifelike pain when taking a deep breath. What does this type of pain likely indicate to the nurse?
Pleurisy Explanation: Pleuritic pain from irritation of the parietal pleura is sharp and seems to "catch" on inspiration; patients often describe it as being "like the stabbing of a knife."
A client with chronic bronchitis is admitted to the health facility. Auscultation of the lungs reveals low-pitched, rumbling sounds. Which of the following describes these sounds?
Rhonchi Explanation: Rhonchi are deep, low-pitched, rumbling sounds heard usually on expiration. The etiology of rhonchi is associated with chronic bronchitis.
In which position should the client be placed for a thoracentesis?
Sitting on the edge of the bed
The nurse is admitting a client who just had a bronchoscopy. Which assessment should be the nurse's priority?
Swallow reflex Explanation: 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.
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?
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.
The client is returning from the operating room following a bronchoscopy. Which action, performed by the nursing assistant, would the nurse stop if began prior to nursing assessment?
The nursing assistant is pouring a glass of water to wet the client's mouth. Explanation: When completing a procedure which sends a scope down the throat, the gag reflex is anesthetized to reduce discomfort. Upon returning to the nursing unit, the gag reflex must be assessed before providing any food or fluids to the client. The client may need assistance following the procedure for activity and ambulation but this is not restricted in the post procedure period.
The adenoids are
clusters of lymph tissue located between the back of the nose and the back of the throat in the nasopharynx.
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?
They can be heard during inspiration and expiration.
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?
They can be heard during inspiration and expiration. Explanation: 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.
Bronchial breath sounds occur in
consolidation, such as pneumonia.
The main function of respiration?
To exchange oxygen and CO2 between the atmospheric air and the blood and between the blood and the cells
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 Explanation: A thoracentesis may be performed to obtain a sample of pleural fluid or to biopsy a specimen from the pleural wall for diagnostic purposes. The fluid, which may be clear, serous, bloody, or purulent, provides clues to the pathology. Bloody fluid may indicate trauma, whereas purulent fluid usually indicates an infection and serous fluid indicates malignancy or heart failure. Pneumothorax, tension pneumothorax, subcutaneous emphysema, and pyogenic infection are complications of a thoracentesis. Pulmonary edema or cardiac distress can occur after a sudden shift in mediastinal contents when large amounts of fluid are aspirated
Which of the following alveolar cells secrete surfactant?
Type II alveolar cells are metabolically active and secrete surfactant, a phospholipid that decrease the surface tension in the alveoli and prevents their collapse.
The epithelium of the alveoli does not contain
Type IV cells
The nursing instructor is teaching a pre-nursing pathophysiology class. The class is covering the respiratory system. The instructor explains that the respiratory system is comprised of both the upper and lower respiratory system. The nose is part of the upper respiratory system. The instructor continues to explain that the nasal cavities have a vascular and ciliated mucous lining. What is the purpose of the vascular and ciliated mucous lining of the nasal cavities?
Warm and humidify inspired air Explanation: The vascular and ciliated mucous lining of the nasal cavities warms and humidifies inspired air. It is the function of the cilia alone to move mucus in the nasal cavities and filter the inspired air.
The central sulcus is
a fold in the cerebral cortex called the central fissure.
When the contrast medium is infused what is often a sensation experienced by the client?
an urge to cough
Sibilant wheezes
are continuous, musical, high-pitched, whistlelike sounds heard during inspiration and expiration.
Blood gas samples are obtained through
arterial puncture at the radial, brachial, or femoral artery. A client also may have an indwelling arterial catheter from which arterial samples are obtained.
Conditions that may alter bronchial diameter and affect airway resistance include
contraction of bronchial smooth muscle (e.g., asthma); thickening of bronchial mucosa (e.g., chronic bronchitis); airway obstruction by mucus, a tumor, or a foreign body; and loss of lung elasticity (e.g., emphysema)
A mechanical ventilator
assists patients who are unable to breathe on their own.
Serous fluid may be associated with
cancer, inflammatory conditions, or heart failure.
To palpate the maxillary sinuses, the nurse should apply gentle pressure in the
cheek area below the eyes, adjacent to the nose.
patient with pulmonary edema would be expected to have
crackles in the lung bases, and possible wheezes.
Sonorous wheezes are
deep, low-pitched rumbling sounds heard primarily during expiration.
Rhonchi are
deep, low-pitched, rumbling sounds heard usually on expiration. The etiology of rhonchi is associated with chronic bronchitis.
Type III cells
destroy foreign material, such as bacteria. alveolar cell macrophages that are large phagocytic cells that ingest foreign matter and act as an important defense mechanism.
Pulse oximetry is a noninvasive method to
determine arterial oxygen saturation. Normal values are 95% and above. Using this diagnostic test first provides rapid information of the client's respiratory system. All other options vary in amount of time and patient participation in determining further information regarding the respiratory system.
what should a nurse do before a pulmonary angiography?
determine if the client has any allergies, particularly to iodine, shellfish, or contrast dye.
During the pulmonary angiography, the nurse should check for signs and symptoms of allergic reactions to the contrast medium, such as
itching, hives, or difficulty in breathing.
Pink, frothy sputum may be an indication of
pulmonary edema. Explanation: Profuse frothy, pink material, often welling up into the throat, may indicate pulmonary edema. Foul-smelling sputum and bad breath may indicate a lung abscess, bronchiectasis, or an infection caused by fusospirochetal or other anaerobic organisms.
In carcinoma, the pain may be
dull and persistent because the cancer has invaded the chest wall, mediastinum, or spine.
Kyphoscoliosis is characterized by
elevation of the scapula and a corresponding S-shaped spine. This deformity limits lung expansion within the thorax. It may occur with osteoporosis and other skeletal disorders that affect the thorax.
The frontal lobe completes
executive functions and cognition.
The nurses inspects for what after a pulmonary angiography?
hematoma, absent distal pulses, after the procedure.
Purulent fluid is the recommended diagnosis for
infection
A pleural friction rub is heard secondary to
inflammation and loss of lubricating pleural fluid.
Type I cells
line most alveolar surfaces. epithelial cells that form the alveolar walls
Thoracentesis, is performed with
local anesthesia
It is important for the nurse to provide required information and appropriate explanations of diagnostic procedures to clients with respiratory disorders in order to
manage decreased energy levels. In addition to the nursing management of individual tests, clients with respiratory disorders require informative and appropriate explanations of any diagnostic procedures they will experience. Nurses must remember that for many of these clients, breathing may in some way be compromised and energy levels may be decreased. For that reason, explanations should be brief, yet complete, and may need to be repeated later after a rest period. The nurse must also ensure adequate rest periods before and after the procedures. After invasive procedures, the nurse must carefully assess for signs of respiratory distress.
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).
Egophony may occur in patients diagnosed with
pleural effusion.
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.
Absent breath sounds occurs in
pneumothorax.
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.
In Cheyne-Stokes respiration,
rate and depth increase, then decrease until apnea occurs.
The pons in the brainstem controls
rate and depth of respirations. When injury occurs or increased intracranial pressure results, respirations are slowed.
Risk factors associated with respiratory disease include
smoking, exposure to allergens and environmental pollutants, and exposure to certain recreational and occupational hazards.
Crackles are
soft, high-pitched, discontinuous popping sounds that occur during inspiration.
Ventilation is
the actual movement of air in and out of the respiratory tract.
A pigeon chest occurs as a result of
the anterior displacement of the sternum, which also increases the anteroposterior diameter. This may occur with rickets, Marfan syndrome, or severe kyphoscoliosis.
The Wernicke's area is
the area linked to speech.
Diffusion is
the exchange of oxygen and CO2 through the alveolar-capillary membrane.
Expiratory reserve volume is
the maximum volume of air that can be exhaled forcibly after a normal exhalation.
Smoking history is usually expressed in pack-years, which is
the number of packs of cigarettes smoked per day times the number of years the patient smoked.
Blood gas samples are not obtained from
the pleural surfaces or trachea and bronchi.
Pulmonary perfusion refers to
the provision of blood supply to the lungs.
In a patient with emphysema
the ribs are more widely spaced and the intercostal spaces tend to bulge on expiration.
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 exhalation.
Funnel chest occurs when
there is a depression in the lower portion of the sternum. This may compress the heart and great vessels, resulting in murmurs. Funnel chest may occur with rickets or Marfan's syndrome.
Which hollow tube transports air from the laryngeal pharynx to the bronchi?
trachea. This is a cartilaginous framework between the pharynx and trachea that produces sound.
The adenoids are usually inspected by
using a special mirror. They cannot be seen by looking directly into the mouth.