Chapter 24 Assessment of the Respiratory System

What kind of breathing might a patient who smokes have?

Cheyenne Stokes

A nurse auscultates a harsh hollow sound over a client's trachea and larynx. What action would the nurse take FIRST?

Document the findings

What are the paranasal sinuses?

air filled cavities within the bones of the skull that surround the nasal passage

A nurse is assessing a client's history of particular matter exposure. What questions are consistent with the I PREPARE tool? SELECT ALL THAT APPLY.

- Investigate all history of known exposures - Determine if breathing problems are worse at work - Ask the client what type of heating in the house - Gather details about the geographic location of the client's home - Have the client list all previous jobs & work experiences - Assess what hobbies the client & family enjoy

A nurse plans care for a client who is at high risk for a pulmonary infection. Which interventions should the nurse include in this client's plan of care? SELECT ALL THAT APPLY.

- encourage deep breathing & coughing - ambulate the client 3 times/day - provide a diet high in protein & vitamins

A nurse assesses a client who is recovering from a thoracentesis. Which assessment findings would alert the nurse to a potential pneumothorax? SELECT ALL THAT APPLY.

- new onset cough - tachypnea - pain with respirations

What does the upper respiratory tract consist of?

- nose - sinus - pharynx - larynx

A nurse prepares a client who is scheduled for a bronchoscopy with transbronchial biopsy procedure at 0900. What actions would the nurse take? SELECT ALL THAT APPLY.

- verify that the informed consent was obtained - document the client's allergies - review laboratory results - monitor the client for at least 24 hours afterwards

A nurse teaches a client who is interested in smoking cessation. Which statements would the nurse include in this client's teaching? SELECT ALL THAT APPLY.

-Find an activity that you enjoy and will keep your hands busy. -Drink at least 8 glasses of water each day. -Make a list of reasons why you want to stop smoking. -Set a quit date and stick to it.

A nurse collaborates with a respiratory therapist to complete pulmonary function tests (PFTs) for a client. Which statements would the nurse include in communications with the respiratory therapist prior to the tests? SELECT ALL THAT APPLY.

-I held the client's morning bronchodilator medication. -I advised the client not to smoke for 6 hours prior to the test. -The client is alert & can follow your commands.

While obtaining a client's health history, the client states, "I'm allergic to avocados, molds, and grass." Which responses by the nurse are BEST? SELECT ALL THAT APPLY.

-What happens when you are exposed to those things? -How do you treat these allergies? -I will document this in your record so everyone knows. -Have you ever been in the hospital after an allergic response?

A nurse assesses a client who is prescribed varenicline for smoking cessation. What signs or symptoms would the nurse identify as adverse effects of this medication? SELECT ALL THAT APPLY.

-visual hallucinations -manic behavior/impaired judgment

Smell uses what cranial nerve?

1

How much sputum can lungs produce a day?

90 mL

What is crepitus?

Air trapped in and under the skin

A nurse cares for a client who had a bronchoscopy 2 hours ago. the client asks for a drink of water. What action would the nurse take NEXT?

Assess the client's gag reflex before giving any food or water.

A nurse is caring for an older patient who has a pulmonary infection. Which action should the nurse take first?

Assess the client's level of consciousness

A nurse plans care for a client who is experiencing dyspnea and must stop multiple times when climbing a flight of stairs. Which intervention would the nurse include in this client's plan of care?

Assistance with ADLs

A nurse assess a client after an open lung biopsy. Which assessment finding is matched with the correct intervention?

Client has reduced breath sounds - nurse calls primary health care provider immediately.

A nurse observes that a client's anteroposterior (AP) chest diameter is the same as the lateral chest diameter. Which question would the nurse ask the client in response to this finding?

Do you have any chronic breathing problems?

Where does oxygen rich blood go?

Left side of the heart

A nurse obtains the heath history of a client who is recently diagnosed with lung cancer and identifies that the client has a 60 pack/year smoking history. Which action is MOST important for the nurse to take when interviewing this client?

Maintain a nonjudgmental attitude to avoid causing the client to feel guilty.

A nurse is caring for a client who received benzocaine spray prior to a recent bronchoscopy. The client presents with continuous cyanosis even with oxygen therapy. What action would the nurse take NEXT?

Notify the Rapid Response Team

A nurse is assessing a client who is recovering from a lung biopsy. The client's breath sounds are absent. While another nurse calls the Rapid Response Team, what action by the nurse takes is MOST important?

Obtain a pulse oximetry reading.

A nurse assesses a client's respiratory status. Which information is MOST important for the nurse to obtain?

Occupation & hobbies.

What is a common sign of pulmonary edema?

Pink, frothy sputum

A nurse teaches a client who is prescribed nicotine replacement therapy. Which statement would the nurse include in this client's teaching?

Smoking while taking this medication will increase your risk of a stroke.

A nurse assess a client after a thoracentesis. Which assessment finding warrants immediate action?

The trachea is shifted toward the opposite side of the neck.

A nurse is caring for a client who is scheduled to undergo a thoracentesis. Which intervention would the nurse complete prior to the procedure?

Validate that informed consent has been given by the client.

What is fremitus?

Vibration of the chest wall when the patient speaks

A nurse is providing care after auscultating clients breath sounds. Which assessment finding is correctly matched to the nurses primary intervention?

Wheezes are heard in central areas. The nurse administers an inhaled bronchodilator.

What would occur without surfactant?

atelectasis

What is peripheral perfusion?

blood pumped through the tissue

What is central perfusion?

force of blood movement generated by cardiac output