Chapter 17: Assessment of Respiratory Function

The nursing instructor is teaching students about the respiratory system. The instructor knows the teaching has been effective when a student makes which statement?

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

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? Select all that apply.

- 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.

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

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

Orthopnea

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

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

Pleurisy

What is the primary function of the larynx?

Producing sound

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 the nurse perform first?

Pulse oximetry

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

Rhonchi

In which position should the client be placed for a thoracentesis?

Sitting on the edge of the bed

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

Tidal volume

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

Use of accessory muscles

What is the difference between respiration and ventilation?

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

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 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

lungs.

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

tidal volume

The volume of air inhaled and exhaled with each breath is termed

tidal volume.

A nurse is caring for an older adult with pneumonia. What are age-related structural and functional changes that occur in the respiratory system? Select all that apply.

- Increased residual volume - Decreased elasticity of the alveolar sacs - Increased diameter of alveolar ducts - Increased thickness of alveolar sacs

A client has recently been diagnosed with malignant lung cancer. The nurse is calculating the client's smoking history in pack-years. The client reports smoking two packs of cigarettes a day for the past 11 years. The nurse correctly documents the client's pack-years as

22.

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