Chapter 20: Assessment of Respiratory Function

A nurse is instructing the client on the normal sensations that can occur when contrast medium is infused during pulmonary angiography. Which client statement demonstrates an understanding of the teaching? "I will feel light-headed when the contrast medium is introduced." "I will feel warm and may have chest pain" "I will feel waves of nausea throughout the procedure." "I will feel a dull pain when the catheter is introduced."

"I will feel warm and may have chest pain" During a pulmonary angiography, a contrast medium is injected into the femoral circulation. When the medium is infused, the client will feel warm and flushed, with a possibility of chest pain. The client will feel pressure when the catheter is inserted. The client does not typically feel light-headed or nauseated during this procedure.

A nurse working in the radiology clinic is assisting with a client after an unusual arterial procedure. What assessment should the nurse notify the health care provider about? Absent distal pulses Raised temperature in the affected limb Excessive capillary refill Flushed feeling in the client

Absent distal pulses When monitoring clients after a pulmonary angiography, nurses must notify the health care provider 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.

If concern exists about fluid accumulation in a client's lungs, what area of the lungs will the nurse focus on during assessment? Anterior bronchioles Bilateral lower lobes Left lower lobe Posterior bronchioles

Bilateral lower lobes Crackles are secondary to fluid in the alveoli and create a soft, discontinuous popping sound. Because fluid creates these adventitious sounds, the principle of gravity will remind the nurse to focus the assessment on the lower portion of the thorax or the lower lobes of the lungs.

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? Respiratory rate Cyanosis Son's statement Crackles

Cyanosis 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.

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? Increased temperature of the room Reduced lighting in the room Placement of the probe on an earlobe Diagnosis of peripheral vascular disease

Diagnosis of peripheral vascular disease 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 preparing a client for bronchoscopy. Which instruction should the nurse give to the client? Do not walk after the procedure for 4 to 6 hours. Do not cough after the procedure until you are walking. Do not talk for 2 hours before the procedure. Do not eat or drink for 6 hours before the procedure.

Do not eat or drink for 6 hours before the procedure. 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 client with sinus congestion complains of discomfort when the nurse is palpating the supraorbital ridges. What sinus is the client referring? Frontal Sphenoidal Maxillary Ethmoidal

Frontal The nurse may palpate the frontal and maxillary sinuses for tenderness. 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). The ethmoidal sinuses are located between the nose and eyes. The sphenoidal sinuses are behind the nose between the eyes.

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 Resting the head on a pillow Lying on the unaffected side Lying flat on the back

In the standing position 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.

What happens to the diaphragm during inspiration? It contracts and flattens. It relaxes and flattens. It relaxes and raises. It contracts and raises.

It contracts and flattens. During inspiration, the diaphragm contracts and flattens, which expands the thoracic cage and increases the thoracic cavity.

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

No sensation during palpation 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.

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 Bronchogenic carcinoma Lung infarction Bacterial pneumonia

Pleurisy 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." In carcinoma, the pain may be dull and persistent because the cancer has invaded the chest wall, mediastinum, or spine.

What is the primary function of the larynx? Preventing infection Facilitating coughing Protecting the lower airway from foreign objects Producing sound

Producing sound The larynx, or voice box, is a cartilaginous framework between the pharynx and trachea. Its primary function is to produce sound. While the larynx assists in protecting the lower airway, this is mainly the function of the epiglottis. Facilitating coughing is a secondary function of the larynx. Preventing infection is the main function of the tonsils and adenoids.

The nurse is caring for a client with chronic obstructive pulmonary disease. The client reports that he is having difficulty breathing and is feeling fatigued. The nurse realizes that this client is at high risk for which condition? Respiratory alkalosis Respiratory acidosis Metabolic acidosis Metabolic alkalosis

Respiratory acidosis Respiratory acidosis occurs when the body is unable to blow off CO2 due to the hypoventilation of disease processes such as COPD. An increase in blood carbon dioxide concentration occurs and a decreased pH causing acidosis. Respiratory alkalosis is a decrease in acidity of the blood and often caused by hyperventilation. Metabolic acidosis and alkalosis are not directly caused by respiratory disorders.

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? Take deep breaths and cough forcefully. Drink 8 oz of water to thin the secretions for expectoration. Use the secretions present in the oral cavity. Tickle the back of the throat to produce the gag reflex.

Take deep breaths and cough forcefully. 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.

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

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

A nurse is assessing a client's respiratory system. Which alveolar cells secrete surfactant to reduce lung surface tension? Type I Type IV Type II Macrophages

Type II There are three types of alveolar cells. Type I and type II cells make up the alveolar epithelium. Type I cells account for 95% of the alveolar surface area and serve as a barrier between the air and the alveolar surface; type II cells account for only 5% of this area but are responsible for producing type I cells and surfactant. Surfactant reduces surface tension, thereby improving overall lung function. Alveolar macrophages, the third type of alveolar cells, are phagocytic cells that ingest foreign matter and, as a result, provide an important defense mechanism. Type IV is not a category of alveolar cells.

A nurse caring for a patient with a pulmonary embolism understands that a high ventilation-perfusion ratio may exist. What does this mean for the patient? Ventilation matches perfusion. Perfusion exceeds ventilation. There is an absence of perfusion and ventilation. Ventilation exceeds perfusion.

Ventilation exceeds perfusion. A high ventilation-perfusion rate means that ventilation exceeds perfusion, causing dead space. The alveoli do not have an adequate blood supply for gas exchange to occur. This is characteristic of a variety of disorders, including pulmonary emboli, pulmonary infarction, and cardiogenic shock.

What would the instructor tell the students purulent fluid indicates? Inflammation Cancer Infection Heart failure

Infection 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.

A pediatrician diagnosed a child with swollen and inflamed adenoids. The nurse practitioner confirmed the diagnosis by: Inspecting the posterior region of the epiglottis. Inspecting the roof of the nasopharynx. Examining the base of the oropharynx. Palpating the throat above the cricoid cartilage.

Inspecting the roof of the nasopharynx. The adenoids are clusters of lymph tissue located between the back of the nose and the back of the throat in the nasopharynx. The adenoids are usually inspected by using a special mirror. They cannot be seen by looking directly into the mouth.

A nurse is performing a physical assessment on a client who has a history of a respiratory infection. Which documentation, completed by the nurse, indicates the resolution of the infection? Select all that apply. Lung fields documented as clear in the bases. Decreased fremitus when the client speaks "99." Bronchovesicular sounds heard over the upper lung fields. Dull sounds percussed over the lung tissue. Palpable vibrations over the chest wall when the client speaks.

Lung fields documented as clear in the bases. Palpable vibrations over the chest wall when the client speaks. Decreased fremitus when the client speaks "99." Bronchovesicular sounds heard over the upper lung fields. To determine if the client's respiratory infection has resolved, the nurse should assess the client's normal respiratory status. Lungs will return to clear breath sounds. Palpable vibrations will be felt, as there is no blockage in the transmission. A client with consolidation of a lobe of the lung from pneumonia has increased tactile fremitus over that lobe. A decreased fremitus would indicate resolution of infection Bronchovesicular sounds will be noted over the upper lung fields. An increased fremitus is noted as the client speaks "99." Dull percussed sounds indicate an area of consolidation.

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? Venous hum Rales Bronchovesicular Rhonchi

Rhonchi Rhonchi or sonorous wheezes are deep, low-pitched, rumbling sounds heard usually on expiration. The etiology of rhonchi is associated with chronic bronchitis. Rales or crackles are soft, high-pitched sounds. A venous hum is a blood flow humming sound. Bronchovesicular sound is an intermediate pitch with expiration and inspiration.

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. They occur when the pleural surfaces are inflamed. They result from air passing through widened air passages. They are heard in clients with decreased secretions.

They can be heard during inspiration and expiration. 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.

The nurse is caring for a client with recurrent hemoptysis who has undergone a bronchoscopy. Immediately following the procedure, the nurse should complete which action? Ensure the client remains moderately sedated to decrease anxiety. Assess the client for a cough reflex. Offer the client ice chips. Instruct the client that bed rest must be maintained for 2 hours.

Assess the client for a cough reflex. After the procedure, the client must take nothing by mouth until the cough reflex returns, because the preoperative sedation and local anesthesia impair the protective laryngeal reflex and swallowing. Once the client demonstrates a cough reflex, the nurse may offer ice chips and eventually fluids. The client is sedated during the procedure, not afterward. The client is not required to maintain bed rest following the procedure.

For air to enter the lungs (process of ventilation), the intrapulmonary pressure must be less than atmospheric pressure so air can be pulled inward. Select the movement of respiratory muscles that makes this happen during inspiration. Intercostals muscles relax to allow for expansion. Anteroposterior rib diameter decreases. Lungs are pulled up and pushed back against the thoracic cage. Diaphragm contracts and elongates the chest cavity.

Diaphragm contracts and elongates the chest cavity. The diaphragm contracts during inspiration and pulls the lungs in a downward and forward direction. The abdomen appears to enlarge because the abdominal contents are being compressed by the diaphragm. With inspiration, the diaphragmatic pull elongates the chest cavity, and the external intercostal muscles (located between and along the lower borders of the ribs) contract to raise the ribs, which expands the anteroposterior diameter. The effect of these movements is to decrease the intrapulmonary pressure.

Which of the following clinical manifestations should a nurse monitor for during a pulmonary angiography, which indicates an allergic reaction to the contrast medium? Hematoma Urge to cough Absent distal pulses Difficulty in breathing

Difficulty in breathing Nurses must determine if the client has any allergies, particularly to iodine, shellfish, or contrast dye. During the procedure, the nurse should check for signs and symptoms of allergic reactions to the contrast medium, such as itching, hives, or difficulty in breathing. The nurses inspects for hematoma, absent distal pulses, after the procedure. When the contrast medium is infused, an urge to cough is often a sensation experienced by the client.

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? Pneumonia Increased intracranial pressure Pulmonary edema Metabolic acidosis

Increased intracranial pressure Bradypnea is associated with increased intracranial pressure, brain injury, and drug overdose. Respirations are slower than the normal rate (<10 breaths/min), with normal depth and regular rhythm. Tachypnea is commonly seen in clients with pneumonia, pulmonary edema, and metabolic acidosis.

The clinical finding of pink, frothy sputum may be an indication of which condition? Pulmonary edema Bronchiectasis Lung abscess Infection

Pulmonary edema 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.

The nurse is caring for a client whose respiratory status has declined since shift report. The client has tachypnea, is restless, and displays cyanosis. Which diagnostic test should be assessed first? Pulse oximetry Arterial blood gases Pulmonary function test Chest x-ray

Pulse oximetry 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.

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. The nursing assistant is assisting the client to a semi-Fowler's position. The nursing assistant is asking a question requiring a verbal response. The nursing assistant is assisting the client to the side of the bed to use a urinal.

The nursing assistant is pouring a glass of water to wet the client's mouth. 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.

Which term refers to the volume of air inhaled or exhaled during each respiratory cycle? Functional residual capacity Maximal voluntary ventilation Vital capacity Tidal volume

Tidal volume 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.

A nurse is discussing squamous epithelial cells lining each alveolus, which consist of different types of cells. Which type of alveolar cells produce surfactant? Type II cells Type III cells Type IV cells Type I cells

Type II cells There are three types of alveolar cells. Type I and type II cells make up the alveolar epithelium. Type I cells account for 95% of the alveolar surface area and serve as a barrier between the air and the alveolar surface; type II cells account for only 5% of this area, but are responsible for producing type I cells and surfactant. Surfactant reduces surface tension, thereby improving overall lung function. Alveolar macrophages, the third type of alveolar cells, are phagocytic cells that ingest foreign matter and, as a result, provide an important defense mechanism. The epithelium of the alveoli does not contain Type IV cells.

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? Crackles Wheezes Rhonchi Rubs

Wheezes A decrease in airway diameter, such as in asthma, produces breath sounds of wheezes. Wheezes are a whistling type of sound relating to the narrowing on the airway. A wheeze can have a high-pitched or low-pitched quality. Crackles, also noted as rales, are crackling or rattling sounds signifying fluid or exudate in the lung fields. Rhonchi are a course rattling sound similar to snoring usually caused by secretion in the bronchial tree. Rubs are secretions that can be heard in the large airway.

Which hollow tube transports air from the laryngeal pharynx to the bronchi? pharynx larynx trachea bronchioles

trachea The trachea is a hollow tube composed of smooth muscle and supported by C-shaped cartilage. The trachea transports air from the laryngeal pharynx to the bronchi and lungs. This is a cartilaginous framework between the pharynx and trachea that produces sound. The bronchioles are smaller subdivisions of bronchi within the lungs. The pharynx, or throat, carries air from the nose to the larynx and food from the mouth to the esophagus.

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% 80% 75% 40%

95% Normal SpO2 values are more than 95%. Values less than 90% indicate that the tissues are not receiving enough oxygen, in which case further evaluation is needed.

The nurse is caring for a client diagnosed with pneumonia. The nurse assesses the client for tactile fremitus by completing which action? Placing the thumbs along the costal margin of the chest wall and instructing the client to inhale deeply Asking the client to say "one, two, three" while the nurse auscultates the lungs Instructing the client to take a deep breath and hold it while the diaphragm is percussed Asking the client to repeat "ninety-nine" as the nurse's hands move down the client's thorax

Asking the client to repeat "ninety-nine" as the nurse's hands move down the client's thorax While the nurse is assessing for tactile fremitus, the client is asked to repeat "ninety-nine" or "one, two, three," or "eee, eee, eee" as the nurse's hands move down the client's thorax. Vibrations are detected with the palmar surfaces of the fingers and hands, or the ulnar aspect of the extended hands, on the thorax. The hand(s) are moved in sequence down the thorax, and corresponding areas of the thorax are compared. Asking the client to say "one, two, three" while auscultating the lungs is not the proper technique to assess for tactile fremitus. The nurse assesses for anterior respiratory excursion by placing the thumbs along the costal margin of the chest wall and instructing the client to inhale deeply. The nurse assesses for diaphragmatic excursion by instructing the client to take a deep breath and hold it while the diaphragm is percussed.

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

Count the rate of respirations. 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 working on a gerontology unit admits a 77-year-old with recent shortness of breath. The nurse knows that the amount of respiratory dead space increases with age. What do these changes result in? Increased ventilation Decreased diffusion capacity for oxygen Increased diffusion of gases Decreased shunting of blood

Decreased diffusion capacity for oxygen The amount of respiratory dead space increases with age. These changes result in a decreased diffusion capacity for oxygen with increasing age, producing lower oxygen levels in the arterial circulation. Shunting does not typically decrease and ventilation does not increase.

The client has just had an invasive procedure to assess the respiratory system. What does the nurse know should be assessed on this client? Loss of consciousness Masses in pleural space Respiratory distress Watery sputum

Respiratory distress After invasive procedures, the nurse must carefully check for signs of respiratory distress and blood-streaked sputum. Masses in the pleural space are a condition that affects fremitus. General examination of overall health and condition includes assessing the consciousness of a client.

The nurse is caring for a client who is to undergo a thoracentesis. In preparation for the procedure, the nurse places the client in which position? Sitting on the edge of the bed Supine Prone Lateral recumbent

Sitting on the edge of the bed If possible, it is best to place the client 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 client 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 the client is unable to assume a sitting position).

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? Central sulcus Wernicke's area The pons The frontal lobe

The pons The inspiratory and expiratory centers in the medulla oblongata and pons control the rate and depth of ventilation. When injury occurs or increased intracranial pressure results, respirations are slowed. The frontal lobe completes executive functions and cognition. The central sulcus is a fold in the cerebral cortex called the central fissure. The Wernicke's area is the area linked to speech.

What is the purpose of the vascular and ciliated mucous lining of the nasal cavities? Move mucus to the back of the throat Moisten and filter expired air Cool and dry expired air Warm and humidify inspired air

Warm and humidify inspired air 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.

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? epiglottis eustachian tubes oropharynx genetics

eustachian tubes 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's infection is not caused by genetics. The oropharynx contains the tongue. The epiglottis closes during swallowing and relaxes during respiration.