Respiratory (Chap. 20)

A client has suspected fluid accumulation in the pleural space of the lungs and is scheduled for a thoracentesis. The nurse will implement which of the following for this procedure?

*Educate the client about the need to cleanse the thoracic area. *Apply pressure to the puncture site after the procedure. *Complete a respiratory assessment after the procedure.

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

A client experiencing hypothermia *Pulse oximetry is a noninvasive method of continuously monitoring the oxygen saturation of hemoglobin

what produces a hyper resonant lung sound?

A hyper resonant sound is an abnormal lower pitched sound that occurs when free air exists in disease processes such as pneumothorax.

Auscultation of the lungs reveals low-pitched, rumbling sounds?

Rhonchi or sonorous wheezes are deep, low-pitched, rumbling sounds heard usually on expiration. *Rhonchi is associated with chronic bronchitis.

What is diffusion?

The movement of particles from an area of high concentration to an area of low concentration. * is the exchange of oxygen and CO2 through the alveolar-capillary membrane.

What position should the client be in for a thoracentesis procedure?

The nurse assists the client to a sitting or side-lying position, which provides support and exposes the base of the thorax.

The nurse is 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?

ABGs determine the blood's pH, oxygen-carrying capacity, levels of oxygen, CO2, and bicarbonate ion. Blood gas samples are obtained through an arterial puncture at the radial, brachial, or femoral artery.

What is air pressure variances?

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

The student nurse is learning breath sounds while listening to a client in the physician's office. An experienced nurse is assisting and notes air movement over the trachea to the upper lungs. The air movement is noted equally on inspiration as expiration. Which breath sounds would the nurse document?

Air movement over the trachea and upper lungs is a normal finding for bronchovesicular sounds. The air movement is noted equally on inspiration as expiration.

residual volume

Amount of air remaining in the lungs after a forced exhalation

The nurse answers a client's call light. The client reports 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 the

Blood from the lung is usually bright red, frothy, and mixed with sputum. Initial symptoms include a tickling sensation in the throat, a salty taste, a burning or bubbling sensation in the chest, and perhaps chest pain, in which case the client tends to splint the bleeding side.

In a patient diagnosed with increased intracranial pressure (IICP), the nurse would expect to observe which of the following respiratory rate or depth?

Bradypnea is a slower than normal rate (<10 breaths/minute), with normal depth and regular rhythm. It is associated with IICP, brain injury, central nervous system depressants, and drug overdose.

30s Report this Question A nurse is preparing a client for bronchoscopy. Which instruction should the nurse give to the client?

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.

The nurse is interviewing a patient who says he has a dry, irritating cough that is not "bringing anything up." What medication should the nurse question the patient about taking?

Common causes of cough include asthma, gastrointestinal reflux disease, infection, aspiration, and side effects of medications, such as angiotensin converting enzyme (ACE) inhibitors.

High or increased compliance occurs in which condition?

Emphysema

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?

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.

What happens to the diaphragm during inspiration?

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

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 enables the physician to view the thoracic cavity with all of its contents in motion. A fluoroscopy more precisely diagnoses the location of a tumor or lesion. An x-ray shows the size, shape, and position of the lungs. An MRI and CT produce axial views of the lungs.

High or increased compliance occurs in which disease process?

High or increased compliance occurs if the lungs have lost their elasticity and the thorax is overdistended, as in emphysema.

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 is an increased rate and depth of breathing that results in decreased PaCO2levels and inspiration and expiration nearly equal in duration This is associated with exertion, anxiety, and metabolic acidosis. This hyperventilation is called Kussmaul respiration if associated with diabetic ketoacidosis or renal origin.

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?

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.

A client arrived in the emergency department with a sharp object penetrating the diaphragm. When planning nursing care, which nursing diagnosis would the nurse identify as a priority?

Impaired Gas Exchange *The diaphragm separates the thoracic and abdominal cavities. On inspiration, the diaphragm contracts and moves downward, creating a partial vacuum. Without this vacuum, air is not as efficiently drawn into the thoracic cavity. Hypoxia or hypoxemia may occur from the poor availability of oxygen.

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 Airflow is decreased with atelectasis, which is a bronchial obstruction from collapsed lung tissue

he nurse enters the room of a client who is being monitored with pulse oximetry. Which of the following factors may alter the oximetry results?

Inaccuracy of results may be from anemia, bright lights, shivering, nail polish, or peripheral vascular disease.

A new nurse auscultates adventitious breath sounds but is not sure what to document and confers with an experienced nurse. This experienced nurse documents a pleural friction rub. Which of the following did the experienced nurse do during her assessment to identify the rub?

Inflammation of the pleural lining can cause a grating, harsh, crackling sound that disappears when the client holds the breath. Coughing does not clear the rub. Rubs are best heard over the lower lateral anterior surface of the thorax.

lung scans that use radioisotopes, what should the client be assessed for?

Iodine allergy

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

Kussmaul respirations are seen in patients with diabetic ketoacidosis.

what produces a dull lung sound?

Lung consolidation such as in pneumonia or fluid accumulation produces the dull sound

A client appears to be breathing faster than during the last assessment. Which of the following interventions should the nurse perform?

Observing the rate and depth of respiration is an important aspect of a nursing assessment.

The nurse is performing an assessment for a patient with congestive heart failure. The nurse asks if the patient has difficulty breathing in any position other than upright. What is the nurse referring to?

Orthopnea (inability to breathe easily except in an upright position) may be found in patients with heart disease and occasionally in patients with chronic obstructive pulmonary disease (COPD).

A patient describes his chest pain as knife-like on inspiration

Pleuritic pain from irritation of the parietal pleura is sharp and seems to "catch" on inspiration. Some patients describe the pain as being "stabbed by a knife.

Pink, frothy sputum may be an indication of

Profuse frothy, pink material, often welling up into the throat, may indicate pulmonary edema.

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 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.

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?

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.

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:

Skin color doesn't affect the mucous membranes. Therefore, the nurse can assess for cyanosis by inspecting the client's mucous membranes. The lips, nail beds, and earlobes are less-reliable indicators of cyanosis because they're affected by skin color.

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

Swallow reflex

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?

Taking deep breaths moves air around the sputum and coughing forcefully moves the sputum up the respiratory tract.

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.

The diaphragm contracts during inspiration and pulls the lungs in a downward and forward direction.

Rhonchi (sonorous wheeze), associated with what condition?

The etiology of rhonchi is associated with chronic bronchitis.

Following an angiography what does the nurse assess for?

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.

Vital capacity

The total volume of air that can be exhaled after maximal inhalation.

vital capacity

The total volume of air that can be exhaled after maximal inhalation.

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

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.

What is the difference between respiration and ventilation?

Ventilation is the actual movement of air in and out of the respiratory tract. Respiration is the exchange of oxygen and CO2 between atmospheric air and the blood and between the blood and the cells.

The nurse documents breath sounds that are soft, with inspiratory sounds longer than expiratory and found over the periphery of the lungs. Which of the following will the nurse chart?

Vesicular breath sounds are heard over the entire lung field except the upper sternum and between the scapulae. Their pitch and intensity are low. Inspiration sounds are longer than expiratory sounds. These are considered normal breath sounds.

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?

When a blood clot exists in a pulmonary vessel (embolus), impaired perfusion results. However, ventilation is adequate.

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?

When the minute ventilation falls, alveolar ventilation in the lungs also decreases, and the PaCO2 increases.

Biot's respiration is

characterized by periods of normal breathing (3 to 4 breaths) followed by a varying period of apnea (usually 10 to 60 seconds).

A patient with pulmonary edema would be expected to have, what lung sounds?

crackles in the lung bases, and possible wheezes

During a preadmission assessment, for what diagnosis would the nurse expect to find decreased tactile fremitus and hyperresonant percussion sounds?

emphysema

Hyperventilation

is an increased rate and depth of breathing.

high ventilation-perfusion ratio

means that ventilation exceeds perfusion, causing dead space. *The alveoli do not have an adequate blood supply for gas exchange to occur

which area of the brain would the nurse realize is responsible for the rate and depth?

medulla oblongata and pons

Tachypnea is associated with

metabolic acidosis, septicemia, severe pain, and rib fracture.

tactile fremitus

palpable vibration, commonly heard with pneumonia

Thoracentesis

performed to aspirate fluid or air from the pleural space.

Egophony may occur in patients diagnosed with ?

pleural effusion

A low ventilation-perfusion ratio exists in

pneumonia

Cheyne-Stokes respiration

respiration, rate and depth increase, then decrease until apnea occurs.

When you think Wheezing?

you think Asthma *The presence of both inspiratory and expiratory wheezing usually signifies asthma if the individual does not have heart failure

Inspiratory reserve volume

Amount of air that can be forcefully inhaled after a normal tidal volume inhalation

Tidal volume

Amount of air that moves in and out of the lungs during a normal breath

The nurse is caring for a patient with a pulmonary disorder. What observation by the nurse is indicative of a very late symptom of hypoxia?

Cyanosis, a bluish coloring of the skin, is a very late indicator of hypoxia

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?

The eustachian tubes connect the pharynx to the middle ear and are the means by which upper respiratory infections spread to the middle ear.

What is the primary function of the larynx?

The larynx, or voice box, is a cartilaginous framework between the pharynx and trachea. Its primary function is to produce sound.

A nurse is teaching a client about the functions of the larynx. What should the nurse include in the teaching?

The larynx, or voice box, is a cartilaginous framework between the pharynx and trachea. Its primary function is to produce sound. The larynx assists in protecting the lower airway. Facilitating coughing is a function of the larynx.

Pulmonary perfusion?

blood flow to the lungs

A client has been newly diagnosed with emphysema. The nurse should explain to the client that by definition, ventilation:

is breathing air in and out of the lungs. *Ventilation is the actual movement of air in and out of the respiratory tract.

Foul-smelling sputum and bad breath may indicate a

lung abscess

When monitoring a patient following a pulmonary angiography, what should the nurse notify the heath care provider for?

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.

Bronchial breath sounds occur in

pneumonia

Absent breath sounds occurs in?

pneumothorax

A silent unit occurs in

pneumothorax or acute respiratory distress syndrome.

Conditions with decreased compliance

pneumothorax, pleural effusion, and acute respiratory distress syndrome (ARDS).

Hypoventilation is

shallow, irregular breathing.

Rales or crackles sound like?

soft, high-pitched sounds.

laryngoscopy

visual examination of the larynx to detect tumors, foreign bodies, nerve or structural injury, or other abnormalities

functional residual capacity

volume of air remaining in the lungs after a normal tidal volume expiration

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, a bluish coloring of the skin, is a very late indicator of hypoxia.

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. What is the reason the client with suspected lung cancer would undergo magnetic resonance imaging (MRI)?

MRI uses magnetic fields and radiofrequency signals to produce a detailed diagnostic image. MRI can visualize soft tissues, characterize nodules, and help stage carcinomas.

Allergic reactions to contrast are?

itching, hives, or difficulty in breathing

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

The use of accessory muscles for respiration indicates the client is having difficulty breathing. Diaphragmatic and pursed-lip breathing are two controlled breathing techniques that help the client conserve energy.