Chp. 20 PrepU Questions: Assessment of Respiratory Function (Exam 1)

A nurse is performing a respiratory assessment on a client with pneumonia. She asks the client to say "ninety-nine" several times. Through her stethoscope, she hears the words clearly over his left lower lobe. What term should the nurse use to document this finding?

Bronchophony

What finding by the nurse may indicate that the patient has chronic hypoxia?

Clubbing of the fingers

The nurse is caring for a patient with extensive respiratory disease. Which of the following is a late sign of hypoxia in the patient?

Cyanosis

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 allergic reaction to the contrast medium?

Difficulty breathing

Lung complication (the ability of the lungs to stretch) is a physical factor that affects ventilation. A nurse is aware that a patient who has lost elasticity in the lund tissue has a condition known as...

Emphysema

What happens to the diaphragm during inspiration?

It contracts and flattens

A pt diagnosed with diabetic ketoacidosis would be expected to have which type of resp. pattern?

Kussmal respiration

When assessing a client, which adaption indicates the presence of respiratory distress?

Orthopnea

A client receiving moderate sedation while undergoing bronchoscopy. Which assessment finding should the nurse attend to immediately?

Oxygen saturation of 90%

A patient describes his chest pain as knife-like on inspiration. Which of the following is the most likely diagnosis?

Pleurisy

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

Your client has just had an invasive procedure to assess the respiratory system. What do you know should be assessed on this client?

Respiratory distress

A client with chronic bronchitis is admitted to the health facility. Auscultation of the lungs reveals low-pitched, rumbling sounds. What disorder describes these sounds?

Rhonchi

The nurse answers the call light of a male patient. The patient is complaining of an irritating tickling sensation in the throat, a salty taste, and a burning sensation in the chest. Upon further assessment, the nurse notes a tissue with bright red, frothy blood at the bedside. The nurse can assume the source of the blood is likely from which of the following?

The lungs

Which of the following alveolar cells secrete surfactant?

Type II

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

Your client is scheduled for a bronchoscopy to visualize the larynx, trachea, and bronchi. What precautions would you recommend to the client before the procedure?

Abstain from food for at least 6 hours before the procedure

Understanding pulmonary physiology, you would expect which of the following to result in decreased gas exchange in older adults?

Alveolar walls contain fewer capillaries

A nurse is preparing a client with a pleural effusion for a thoracentesis. The nurse should:

Assist the client to a sitting position on the edge of the bed, leaning over the bedside table.

If concern exists about fluid accumulation in a client's lungs, what area of the lungs will the nurse focus on during assessment?

Bilateral lower lobes

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?

Cyanosis

The nursing instructor is talking with senior nursing students about diagnostic procedures used in respiratory diseases. The instructor discusses thoracentesis, defining it as a procedure preformed for diagnostic purposes or to aspirate accumulated excess fluid or air form the pleural space. What would the instructor tell the students purulent fluid indicates?

Infection

The nurse is caring for a clinet with hypoxemia of unknown cause. WHich of teh following oxygen transport considerations does thenurse identify as crucial to circulate oxygen in the body system? Select all

Oxygen is dissolved, oxyhemoglobin circulates to the body tissue, adequate RBCs are needed for oxygen transport

The nurse is caring for a patient with suspected lung cancer. Which of the following imaging studies is more accurate in detecting malignancies than a CT scan?

PET scan

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 HCO of 28 mEq.L. The nurse reports to the physician what finding?

Resp. acidosis

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

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

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 resp. status, which area of the brain would the nurse realize irresponsible for the rate and depth?

The pons

The instructor of the pre-nursing physiology class is explaining respiration to the class. What does the instructor explain is 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 nurse caring for a patient with a pulmonary embolism understands that a high ventilation-perfusion ration may exist. What does this mean for the patient?

Ventilation exceeds perfusion

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 is performing chest auscultation for a patient with asthma. How does the nurse describe the high-pitched, sibilant, musical sounds that are heard?

Wheezes

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%

The nurse would question the accuracy of a pulse oximetry evaluation of what condition?

A client experiencing hypothermia

A nurse practitioner diagnosed a patient with an infection in the maxillary sinuses. Select the area that the nurse palpated to make that diagnosis.

On the cheeks below the eyes

The nurse working in the radiology clinic is assisting with the 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 admitting a clinet who just had a bronchoscopy. Which assessment should be the nurse's priority?

Swallow reflex

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 term for the volume of air inhaled and exhaled with each breath is...

tidal volume

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

Assess the pt. for a cough reflex

A clinet has a nursing diagnosis of "ineffective ariway clearance" as a result of excessive secretions. What would the appropriate outcome for this client be?

Lungs are clear on auscultation

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

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

Tidal volume

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

Use of accessory muscles

While auscultating the lungs of client with asthma, the nurse hears a continuous, high-pitched whistling sound on expiration. The nurse will document this sound as which of the following?

Wheezes

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

no sensation during palpation

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