Respiratory System Quiz (wk 7)

Which assessment finding will the nurse document for a patient with chronic respiratory disease?

The patient's distal phalanx is clubbed. Clubbing of the distal phalanx occurs with chronic respiratory disease following the growth of vascular connective tissue. Cutaneous angiomas, or spider nevi, are noted in the patient with liver disease. Cerebral hypoxia may cause excessive drowsiness. It may also cause the patient to be restless, anxious, and irritable.

The nurse is assessing the chest of a patient for symmetric expansion. Arrange the steps in the order in which the nurse would do the assessment.

1. Put the hands sideways on the posterolateral chest wall. 2. Have the thumbs meet together at the T9 or T10 level. 3. Slide hands medially to pinch the skin between the thumbs. 4. Ask the patient to inhale and take a deep breath. 5. The nurse should note thumb movement.

Assessment for symmetric expansion

the nurse places his or her hands sideways on the posterolateral chest wall. The nurse places the thumbs such that they point together at the level of T9 or T10. The nurse then slides the hands medially to pinch up the skin between the thumbs. The nurse asks the patient to inhale and take a deep breath. As the patient inhales deeply, the thumbs should move apart symmetrically in a normal condition. The hands serve as mechanical amplifiers. The nurse must observe for any lag in expansion.

Which statement describes the structure of the lungs?

"The right lung is shorter and wider than the left lung." The lungs are paired, but are not symmetric structures. The right lung is shorter than the left lung because of the liver present below it. The right lung is wider because the heart bulges to the left. The right lung has three lobes, whereas the left lung has two lobes. The trachea lies anterior to the esophagus. It begins at the level of the cricoid cartilage in the neck and bifurcates just below the sternal angle into the right and the left main bronchi. Each lung contains millions of alveoli.

Which breath sounds heard upon auscultation does the nurse consider normal? Select all that apply.

-bronchial -vesicular -bronchovesicular There are three normal breath sounds. Bronchial breath sounds are high-pitched and loud. Vesicular sounds are low-pitched and soft, and sound more like rustling of the leaves in the wind. Brochovesicular sounds are moderate in pitch and are equal in duration during inspiration and expiration. Crackles and wheezes are abnormal breath sounds. Crackles are discontinuous popping sounds heard during inspiration. Wheezes are continuous musical sounds heard mainly during expiration.

How many thoracic vertebrae are present in the human body?

12 In vertebrates, thoracic vertebrae are present in the middle segment of the vertebral column, between the cervical vertebrae and the lumbar vertebrae. There are 12 thoracic vertebrae present in the human body. The sizes of thoracic vertebrae are between those of the cervical and the lumbar vertebrae. There are 7 cervical, 5 lumbar, and 6 sacrococcygeal vertebrae.

How does the nurse assess for tactile fremitus in a patient?

By placing the palmar base of one hand to touch the patient's chest The nurse uses either the palmar base of the fingers or the ulnar edge of one hand to touch the patient's chest. The patient is asked to repeat resonant phrases such as "ninety-nine" or "blue moon." These phrases generate strong vibrations. The nurse can confirm symmetric chest expansion by placing the warmed hands sideways on the posterolateral chest wall with the thumbs pointing together at the thoracic ninth or tenth vertebra. The nurse places the thumb on the spinous process of the patient to assess the posterior chest. To assess the lymph nodes, the nurse places the fingertips on the sides of the neck of the patient.

What should the nurse expect to assess when auscultating the lung sounds of a patient with heart failure?

Crackles in the lung bases The nurse is likely to hear crackles at the lung bases. Occasional wheezing may be identified while auscultating the patient with emphysema. Crackles over the upper lobes are heard in the patient with tuberculosis. Bilateral wheezing may heard in the patient with asthma.

The nurse is assessing a patient for shortness of breath (SOB). What term should the nurse use to document night sweats associated with shortness of breath?

Diaphoresis Diaphoresis is night sweats related to shortness of breath. Chronic dyspnea is SOB lasting for more than 1 month. It may have neurogenic, respiratory, or cardiac origin. Orthopnea refers to difficulty in breathing when a person is lying in the supine position. If the patient requires two pillows to breathe comfortably while lying down, the nurse notes the condition as two-pillow orthopnea. A patient with paroxysmal nocturnal dyspnea may awaken from sleep with SOB. This patient may need to be upright in order to achieve comfort.

Which structure separates a patient's thoracic cavity from the abdomen?

Diaphragm The thoracic cage is defined by the sternum, ribs, the 12 thoracic vertebrae, and the diaphragm. The diaphragm is a musculotendinous septum that separates the thoracic cavity from the abdomen, and it makes up the floor of the thoracic cage. The manubrium and the xiphoid process are both parts of the sternum, which runs down the center of the ribcage. None of these structures separate the thoracic cavity from the abdomen.

While auscultating the chest, the nurse asks the patient to phonate a long "ee-ee-ee-ee" sound. Through the stethoscope, the nurse hears a long "aaaaa" sound. Which voice sound is present?

Egophony Egophony in Greek means "the voice of a goat" and occurs when there is any consolidation or compression of the chest. The nurse auscultates the chest while the patient makes a long "ee-ee-ee-ee" sound. Through the stethoscope, the nurse hears a bleating long "aaaaa" sound. This change of sound occurs over the area of consolidation or compression. In bronchophony, the patient is asked to repeat "ninety-nine." Through the stethoscope, the words are more distinct than normal, and the sounds are close to the ears of the nurse. This occurs when the pathology increases the lung density. In whispered pectoriloquy, the patient is asked to whisper a phrase such as "one-two-three." The nurse auscultates through the stethoscope to hear a clear, distinct, but faint whispering sound. A sonorous wheeze used to be known as rhonchi; the sounds produced have a snoring and gurgling quality.

What does the term hypercapnia indicate about a patient's respiratory status?

Increased carbon dioxide in the blood Respiration helps maintain the pH of the blood by supplying oxygen to the blood and eliminating excess carbon dioxide. Hypercapnia is the term used to describe an increase in the carbon dioxide levels in the blood, and this is the normal stimulus for breathing. Hyperventilation is the presence of rapid, deep breathing in an individual that causes the carbon dioxide to be blown off. On the other hand, hypoventilation causes carbon dioxide to build up in the blood. A decrease in oxygen in the blood is referred to as hypoxemia. Hypoxemia also increases the respiration, but it is less effective than hypercapnia.

The nurse notices that a patient occasionally sighs when breathing. What should the nurse expect to happen as a result of sighing?

It expands the alveoli. Occasional sighing punctuates the normal breathing pattern and helps to expand the alveoli. Frequent sighing may indicate emotional dysfunction, leading to hyperventilation and dizziness. It does not cause tachypnea or rapid, shallow breathing; instead, it may increase the rate and the depth of breathing. Occasional sighing causes hyperventilation, not hypoventilation, and does not lead to bradypnea or slow breathing.

What is the main function of the respiratory system?

It helps in oxygen utilization. Respiration is the oxidative breakdown of carbohydrates to produce energy. Oxygen is utilized in this process. Respiration does not trap energy; rather, it produces energy. The process called photosynthesis traps energy. Air is moved in and out of the chest by the process of breathing. Respiration is a biochemical process in which carbon dioxide is produced as a byproduct. The body does not require carbon dioxide.

The nurse is assessing the lungs of the patient on the anterior side of the chest. Where would the nurse find the highest point of the lung?

It is found up to 3 to 4 cm above the clavicle. In the anterior chest, the apex or highest point of the lung tissue is 3 to 4 cm above the clavicles. The clavicle, commonly known as the collarbone, is located between the sternum and the scapula. Posteriorly, the location of the seventh cervical vertebra marks the apex of the lung tissue. The base, or the lower border of the lung, rests on the diaphragm at about the sixth rib in the midclavicular line. Deep inspiration expands the lungs, and the lower border of the lungs drops up to the twelfth thoracic vertebra.

The nurse is assessing the bronchial breath sounds of a patient. Where should the nurse place the stethoscope?

Over the trachea and the larynx The nurse should place the stethoscope over the trachea and the larynx to listen to bronchial breath sounds. These sounds have a high pitch, loud amplitude, with a harsh or hollow tubular quality. The nurse auscultates over the peripheral lung fields to note vesicular breath sounds. The nurse listens for bronchovesicular breath sounds over major bronchi with fewer alveoli. These are found on the posterior side between the scapulae and on the anterior side around the upper sternum and in the first and second intercostal spaces.

The nurse is assessing the respiratory pattern of an adult patient. Which assessment finding should the nurse document as abnormal?

Respiratory rate is 24 to 30 per minute. The normal respiratory rate for an adult is 10 to 20 breaths per minute. An increase in the respiratory rate is normal with fear, fever, or exercise. It may also indicate respiratory insufficiency, pneumonia, alkalosis, pleurisy, and lesions in the pons. Normally, the ratio of pulse to respirations is 4:1. Both the values tend to increase with fear, fever, or exercise. The normal respiratory depth or the air moving in and out with each respiration is 500 to 800 mL. Moreover, the respiratory pattern is also normally even.