PrepU 20: Assessment of Respiratory Function

What is the difference between respiration and ventilation?

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

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%

A nurse would question the accuracy of a pulse oximetry evaluation in which of the following conditions?

A client experiencing hypothermia

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

High or increased compliance occurs in which disease process?

Emphysema

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

The amount of air inspired and expired with each breath is called:

tidal volume.

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

tidal volume.

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 warm and may have chest pain"

A client is seen in the emergency room for a case of diabetic acidosis with the presence of Kussmaul respirations. What client condition is associated with the presence of Kussmaul respirations?

Hyperventilation

A client with sinus congestion complains of discomfort when the nurse is palpating the supraorbital ridges. What sinus is the client referring?

Frontal

For which reason does gas exchange decrease in older adults?

The alveolar walls contain fewer capillaries.

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.

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

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

trachea

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.

The nurse is caring for a client with an exacerbation of COPD and scheduled for pulmonary function studies using a spirometer. Which client statement would the nurse clarify?

"I will breathe in through my mouth and out through my nose."

Which of the following disease processes cause increased compliance?

Emphysema

The nurse is reviewing the blood gas results for a patient with pneumonia. What arterial blood gas measurement best reflects the adequacy of alveolar ventilation?

PaCO2

The nurse is taking a respiratory history for a patient who has come into the clinic with a chronic cough. What information should the nurse obtain from this patient? (Select all that apply.)

- Occupational and environmental influences - Previous history of lung disease in the patient or family - Previous history of smoking

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.

- Palpable vibrations over the chest wall when the client speaks. - Lung fields documented as clear in the bases. - Bronchovesicular sounds heard over the upper lung fields.

The nurse inspects the thorax of a patient with advanced emphysema. The nurse expects chest configuration changes consistent with a deformity known as:

Barrel chest

A client presents to the emergency department with fluid overload. The nurse is concerned about fluid accumulation in the lungs. On which of the following areas would the nurse focus the lung assessment?

Bilateral lower lobes

A nurse is preparing a client for bronchoscopy. Which instruction should the nurse give to the client?

Do not eat or drink for 6 hours before the procedure.

What would the instructor tell the students purulent fluid indicates?

Infection

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

Kussmaul respirations

The clinical finding of pink, frothy sputum may be an indication of which condition?

Pulmonary edema

Which ventilation-perfusion ratio is exhibited by acute respiratory distress syndrome (ARDS)?

Silent unit

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.

Which term refers to the volume of air inhaled or exhaled during each respiratory cycle?

Tidal volume

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

Clubbing of the fingers

A black client with asthma seeks emergency care for acute respiratory distress. Because of this client's dark skin, the nurse should assess for cyanosis by inspecting the:

mucous membranes.

Pink, frothy sputum may be an indication of

pulmonary edema.

The nurse is performing an assessment of a patient who arrived in the emergency department with a barbiturate overdose. The respirations are normal for 3 to 4 breaths followed by a 60-second period of apnea. How does the nurse document the respirations?

Biot's respirations

The nurse is assessing a patient in respiratory failure. What finding is a late indicator of hypoxia?

Cyanosis

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 obtaining a health history from a client who reports hemoptysis for the past 2 months. The client reports occasional dyspnea. Which imaging study, ordered by the physician, will view the thoracic cavity while in motion?

Fluoroscopy

Which respiratory volume is the maximum volume of air that can be inhaled after a normal exhalation?

Inspiratory reserve volume

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.

A patient exhibited signs of an altered ventilation-perfusion ratio. The nurse is aware that adequate ventilation but impaired perfusion exists when the patient has which of the following conditions?

Pulmonary embolism

A client with chronic bronchitis is admitted to the health facility. Auscultation of the lungs reveals low-pitched, rumbling sounds. Which term should the nurse document?

Rhonchi

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 exceeds perfusion.

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.

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?

Wheezes

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

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

The nurse is in the radiology unit of the hospital. The nurse is caring for a client who is scheduled for a lung scan. The nurse knows that lung scans need the use of radioisotopes and a scanning machine. Before the perfusion scan, what must the client be assessed for?

Iodine allergy

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

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

Orthopnea

While auscultating the lungs of a 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

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