Chapter 20 Prep-U Questions

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

Swallow reflex

You are caring for a client who is in respiratory distress. The physician orders arterial blood gases (ABGs) to determine various factors related to blood oxygenation. What site can ABGs be obtained from?

A puncture at the radial artery

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

The nurse is caring for a patient who is to undergo a thoracentesis. In preparation for the procedure, the nurse will position the patient in which of the following positions?

Sitting on the edge of the bed.

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 abnormally in ventilation control?

Aortic arch, pons, and CO2 receptor sites

The nurse is caring for a patient with recurrent hemoptysis who has undergone a bronchoscopy. Immediately following the procedure, the nurse should complete which of the following?

Assess the patient for a cough reflex

which of the following is a deformity of the chest that occurs as a result of over inflation of the lungs?

Barrel chest

Which of the following is a true statement regarding air pressure variances? A.)The thoracic cavity becomes smaller during inspiration B.)Air flows from a region of lower pressure to a region of higher pressure during inspiration. C.) Air is drawn through the trachea and bronchi into alveoli during inspiration. D.) The diaphragm contracts during inspiration.

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

The nurse is assessing the lungs of a patient diagnosed with pulmonary edema. Which of the following would be expected upon auscultation?

Crackles at lung bases. A patient with pulmonary edema would be expected to have crackles in the lung bases, and possible wheezes.

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

Decreased size of the airway

While conducting the physical examination during assessment of the respiratory system, which of the following conditions does a nurse assess by inspecting and palpating the trachea?

Deviation from the midline

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.

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

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.

The nurse is caring for a critically ill patient in the ICU. The nurse documents the patient's respiratory rate as bradypnea. The nurse recognizes bradypnea is associated with which of the following conditions?

Increased intracranial pressure Bradypnea is associated with increased intracranial pressure, brain injury, and drug overdose.

A patient diagnosed with diabetic ketoacidosis would be expected to have which type of respiratory pattern?

Kussmaul respirations

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

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.

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.

Why is it important for a nurse to provide required information and appropriate explanations of diagnostic procedures to patients with respiratory disorders?

Manage decreased energy levels

Upon palpation of the sinus area, what would the nurse identify as a normal finding?

No sensation during palpation

What is the primary function of the larynx?

Producing sound

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

The nurse is caring for a client with chronic obstructive pulmonary disease. The client calls the doctor and states having difficulty breathing and overall feeling fatigued. The nurse realizes that this client is at high risk for which condition?

Respiratory acidosis Respiratory acidosis occurs when the body is unable to blow off CO2 due to the hypoventilation of disease processes such as COPD.

A nurse is reviewing arterial blood gas results on an assigned client. The pH is 7.32 with PCO2 of 49 mm Hg and a HCO3 of 28 mEq/L The nurse reports to the physician which finding?

Respiratory acidosis. Analysis of the blood gases reveal that the client is acidotic with a pH under 7.35. Also noted is the PCO2 above the normal range of 30 to 40 mm Hg. The HCO3 is slightly elevated because the normal level is 22 to 26 mEq/L

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 The pons in the brainstem controls rate and depth of respirations. When injury occurs or increased intracranial pressure results, respirations are slowed.

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.

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.

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 volume of air inhaled and exhaled with each breath is termed which of the following?

Tidal Volume

Knowing respiratory physiology is important to understand how the disease process can work within that system. Which hollow tube transports air from the laryngeal pharynx to the bronchi?

Trachea

The squamous epithelial cells lining each alveolus consist of different types of cells. Which type of the alveoli cells produce surfactant?

Type II cells

A nurse assesses the client's respiratory status. Which observation indicates that the client is having difficulty breathing?

Use of accessory muscles.

You are caring for a 65-year-old client who has been newly diagnosed with emphysema. The client is confused by the new terms and wants to know what ventilation means. Which of the following can instruct this client?

Ventilation is breathing air in and out of the lungs.

What is the difference between respiration and ventilation?

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

The nurse auscultates lung sounds that 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

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