Chapter 17 Respiratory System

The nurse is providing care to a client in the emergency department who received a breathing treatment earlier. The nurse is now preparing the client for a procedure and notes that the client is breathing in a shallow manner and the client's hands are trembling. Which action will help decrease the client's level of anxiety? 1. The nurse should explain all procedures in a calm and reassuring voice. 2. Request the immediate presence of the healthcare provider. 3. Provide oxygen for the client. 4. Postpone the procedure.

Correct Answer: 1 Clients experiencing anxiety may demonstrate trembling hands and a shallow breathing pattern. Certain drugs, such as bronchodilators, are used in the treatment of respiratory conditions and may cause the hands to tremble visibly. The nurse should not confuse this sign with nervousness. Even mild respiratory distress is frightening for the client and family. Proceeding in a calm and reassuring manner helps reduce the client's fear. At this time, there is no reason to request the presence of the healthcare provider. There is not enough information about the information to assume the client requires oxygen. The nurse does not need to postpone the procedure.

A preschool client's respiratory rate is 30 per minute. The mother states, "That seems like a really high number. My healthcare provider told me my respiratory rate is only 16 per minute." Which response by the nurse is the most appropriate? 1. "This is a normal finding for your child's age." 2. "Your child is exhibiting a sign of a respiratory infection." 3. "Your child requires further assessment." 4. "Your child may simply be anxious."

Correct Answer: 1 It is normal for children up to the age of 5 to have respiratory rates of up to 35 per minute. The other explanations are not appropriate for this situation. This child is not exhibiting a sign of a respiratory infection. The child does not require further assessment. The child's respiratory rate will increase with anxiety and the child may exhibit tachypnea.

As the nurse assesses the pregnant client, the client states that she sometimes feels like she has difficulty breathing. The client has reached the 36th week of her pregnancy. Which is the reason that the client is experiencing this phenomenon? 1. The fetus is pushing the diaphragm upwards. 2. Fatigue due to the pregnancy. 3. Anxiety about her impending delivery. 4. Contractions.

Correct Answer: 1 While the pregnant female is at rest, the diaphragm rises into the chest to accommodate the fetus. Shortness of breath and dyspnea, especially in the last trimester, are common as the maternal and fetal demand for oxygen increases. The remaining choices are not applicable for this situation.

Select all that apply. The nurse is examining an African American client. When compared to Caucasian client, which conditions is this client at a higher risk for developing? 1. Asthma. 2. Sarcoidosis. 3. Tuberculosis. 4. Obstructive sleep apnea. 5. Chronic bronchitis.

Correct Answer: 1, 2, 3, 4 Asthma, sarcoidosis, TB, and obstructive sleep apnea occur more frequently in African Americans than in Caucasians. African Americans are not necessarily more likely to develop chronic bronchitis.

Select all that apply. The nurse is assessing a client with a severe left pleural effusion. Which assessment data does the nurse anticipate based on the client's diagnosis? 1. Absent breath sounds on the left side. 2. Tracheal shift to the right. 3. Hyperresonance upon percussion. 4. Bronchial breath sounds of the right side. 5. Pleural friction rub auscultated.

Correct Answer: 1, 2, 5 In this condition, fluid accumulates in the pleural space and may result in absent breath sounds on the affected side, a tracheal shift to the unaffected side, and a pleural friction rub. The trapping of air in the alveoli will produce a sound of hyperresonance upon percussion. This is not a typical finding in someone who has been diagnosed with a pleural effusion. Bronchial breath sounds of the right side are not a typical finding in someone who has been diagnosed with a pleural effusion.

Select all that apply. While palpating respiratory expansion on a client the nurse notes movement on only one side of the chest. Which conditions are associated with this assessment finding? 1. Atelectasis. 2. Chronic bronchitis. 3. Lobar pneumonia. 4. Pleural effusion. 5. Congestive heart failure.

Correct Answer: 1, 3, 4 Atelectasis is a condition in which there is an obstruction of airflow. Lung tissue may collapse from airway obstruction, such as a mucous plug, lack of surfactant, or a compressed chest wall. Atelectasis will result in decreased lung expansion on the client's affected side. Lobar pneumonia is due to an infection that causes fluid, bacteria, and cellular debris to fill the alveoli. It may result in decreased lung expansion on the client's affected side. Pleural effusion refers to fluid accumulating in the pleural space. It may result in decreased lung expansion on the client's affected side. Chronic bronchitis results in chronic inflammation of the tracheobronchial tree, which leads to increased mucous production and blocked airways. It does not result in decreased lung expansion on one side. Congestive heart failure occurs when increased pressure in the pulmonary veins causes interstitial edema around the alveoli and may cause edema of the bronchial mucosa. It does not result in decreased lung expansion on one side.

Select all that apply. The nurse auscultates the client's lungs and prepares to document the assessment. Which breath sounds are considered abnormal and may require further intervention? 1. Crackles. 2. Vesicular. 3. Bronchovesicular. 4. Wheezes. 5. Bronchial.

Correct Answer: 1, 4 Crackles are adventitious, or abnormal, lung sounds produced by collapsed or fluid-filled alveoli. Wheezes are the result of blocked airflow as in asthma, infection, or due to a foreign body. Vesicular sounds are normal and can be heard over the apices. Bronchovesicular sounds are normal sounds that can be auscultated over the bronchi. Bronchial sounds are normal and can be heard to the right and left of the trachea over the bronchi.

The nurse is preparing to assess an older adult client diagnosed with emphysema. Which anatomical change does the nurse anticipate when performing this client's assessment? 1. Funnel chest. 2. Barrel chest. 3. Pigeon chest. 4. Scoliosis.

Correct Answer: 2 Clients with chronic obstructive pulmonary disease often have barrel chests. Aging can result in a barrel chest. Funnel chest is a congenital deformity characterized by depression of the sternum and adjacent costal cartilage. Pigeon chest is a congenital deformity that is characterized by forward displacement of the sternum with depression of the adjacent costal cartilage. Scoliosis is a condition in which there is lateral curvature and rotation of the thoracic and lumbar spine.

The client is 36 weeks pregnant. The nurse is assessing the client's respiratory system and finds that the respiratory rate is 24 breaths per minute. The client states that she sometimes experiences shortness of breath. Which response by the nurse is the most appropriate? 1. "You have developed asthma during your pregnancy." 2. "During your last trimester, it is normal for you to feel short of breath and to have a faster respiratory rate." 3. "I'm going to have to notify your healthcare provider right now about these findings." 4. "You have been infected with tuberculosis."

Correct Answer: 2 Shortness of breath, dyspnea, and an increased respiratory are normal findings during the last trimester of pregnancy as the woman's chest expands to accommodate the growing baby. The pregnant client has not developed asthma. Asthma is a chronic hyperreactive condition resulting in bronchospasm, mucosal edema, and increased mucus secretion. This usually occurs in response to inhaled irritants or allergens. These are normal findings for this pregnant client and the healthcare provider would not need to be notified. The client has not developed tuberculosis.

The nurse documents that the client's respirations are shallow and rapid with a rate of 30 breaths per minute. Based on these assessment findings, which conclusion by the nurse is the most appropriate? 1. Client fatigue. 2. Client anxiety. 3. Normal client finding. 4. Client boredom.

Correct Answer: 2 Tachypnea, or rapid, shallow respirations, are greater than 24 per minute and may be caused by fever, fear, exercise, respiratory insufficiency, pleuritic pain, alkalosis, or pneumonia. Fatigue does not usually result in tachypnea. Normal respirations are even and regular. A normal respiratory rate is over 10 and under 24 respirations per minute. The bored client may exhibit a slower respiratory rate.

During the respiratory assessment of a client the nurse wishes to locate the angle of Louis. Which landmarks will the nurse use to identify this structure? 1. Clavicle. 2. Sternum. 3. First rib. 4. Vertebral column.

Correct Answer: 2 The angle of Louis is the horizontal ridge formed by the intersection of the manubrium and the body of the sternum.

During the assessment of a client's voice sounds, the nurse hears louder sounds over the client's right lower lobe. The nurse suspects the client has which condition based on this assessment finding? 1. Atelectasis. 2. Lobar pneumonia. 3. Asthma. 4. Pleural effusion.

Correct Answer: 2 Voice sounds are increased and clearer over areas affected by lobar pneumonia. Voice sounds are decreased or absent over areas of atelectasis, asthma, pleural effusion, and pneumothorax.

Select all that apply. The nurse is preparing an educational program regarding Healthy People 2020. Which pieces of information are important to include for caregivers of infants and young children? 1. "Infants should always be placed to sleep on their sides." 2. "Children should be taught to wash their hands." 3. "Caregivers should ensure that the children's toys are age-appropriate." 4. "Parents should be encouraged to avoid immunizations." 5. "Caregivers should inspect the children's toys for small possibly inhalable parts."

Correct Answer: 2, 3, 5 Children should be taught hygiene measures such as handwashing to prevent the spread of infection. Age-appropriate toys should be provided for children to ensure that young infants or children do not inhale small parts or choke on plastic bags that may found in toys meant to be played with by older children. Caregivers should ensure that they are providing toys that are safe. Infants who sleep on their backs have a reduced risk of developing sudden infant death syndrome (SIDS). Children should be immunized to prevent the spread of preventable infections. Some toys may include inhalable parts.

The nurse is assessing a 1-month-old infant's respiratory system and sees that the infant is primarily using abdominal muscles to breathe and has an irregular breathing pattern. Which conclusion by the nurse is appropriate based on this observation? 1. The infant is experiencing respiratory distress. 2. The infant has developed pneumonia. 3. The infant is exhibiting a normal respiratory pattern. 4. The infant has developed a pneumothorax.

Correct Answer: 3 Abdominal breathing is the normal pattern for an infant and continues during childhood until ages 5-7, when the child develops costal breathing patterns. It is normal for an infant to exhibit an irregular breathing pattern. Intercostal muscle retraction and prominent sternocleidomastoids may be seen in respiratory distress. This infant is not exhibiting any signs of respiratory distress. Infants are more susceptible to pneumonia than other populations, but this infant is not exhibiting any clinical manifestations of pneumonia. A pneumothorax is a condition in which air moves into the pleural space and causes partial or complete collapse of the lung. The client with a pneumothorax will exhibit tachypnea, decreased expansion of the chest wall on the affected side, and a tracheal shift to the unaffected side.

While the client sleeps, the nurse notes that the client's respirations periodically stop. Which term will the nurse use to document this finding in the medical record? 1. Tachypnea. 2. Bradypnea. 3. Apnea. 4. Atelectasis.

Correct Answer: 3 Apnea is the cessation of breathing lasting from a few seconds to a few minutes. Tachypnea is a term used to describe rapid, shallow respirations that are greater than 24 per minute. Bradypnea is a term used to describe slow, regular respirations that are less than 10 per minute. The findings do not indicate atelectasis, which is alveolar or lung collapse.

A client with chronic bronchitis is admitted to the hospital. The nurse inspects the client while assessing the client's respiratory system. Which assessment finding is expected? 1. Fever. 2. Decreased respiratory rate. 3. Use of accessory muscles. 4. Dry cough.

Correct Answer: 3 Chronic inflammation of the tracheobronchial tree leads to increased mucous production and blocked airways, causing decreased air movement in and out of the alveoli, which in turn causes the client's respiratory rate to increase in order to compensate. The muscles of the chest wall work harder to try to pull more air into the alveoli, which causes increased chest wall expansion. The use of accessory muscles to breathe may be noted. The client will not typically experience a fever. Fevers are associated with infections. The respiratory rate may be elevated to compensate for the inability to breathe properly. This client will most likely exhibit a chronic productive cough.

A client is experience tachypnea with anxiety and is "hyperventilating." Based on this assessment, which finding does the nurse anticipate for this client? 1. Pleuritic pain. 2. Congestive heart failure. 3. Increased carbon dioxide levels. 4. Reduced oxygen capacity.

Correct Answer: 3 During expiration, the carbon dioxide is expelled. Poor exhalation that occurs with hyperventilation leads to retention of carbon dioxide. Pleurisy results in pleuritic pain. This client is not at risk for developing congestive heart failure. The client's oxygen capacity at this time is increased.

The nurse percusses the lungs and determines that there is an area of hyperresonance. Based on this finding, which condition does the nurse suspect? 1. Pneumonia. 2. Atelectasis. 3. Pneumothorax. 4. Pleural effusion.

Correct Answer: 3 Hyperresonance can be auscultated in clients with conditions that involve overinflated lungs, such as emphysema, and with pneumothorax. When percussing a client with pneumonia, atelectasis, or a pleural effusion, the nurse would hear dullness over the affected area.

The nurse is assessing the client and notes low-pitched, continuous respiratory sounds that have a snoring quality while auscultating the client's lungs. Which term would the nurse use when documenting this finding? 1. Rales. 2. Crackles. 3. Rhonchi. 4. Wheezes.

Correct Answer: 3 There are two types of continuous respiratory sounds that may be heard during the respiratory cycle. Rhonchi are low-pitched and have a snoring quality, while wheezes are high-pitched with a shrill quality. Rales are intermittent, nonmusical, brief sounds. Coarser and louder rales are referred to as crackles.

The nurse is percussing the anterior chest of an older adult client. Which finding does the nurse anticipate for this client based on the age? 1. Flatness. 2. Dullness. 3. Tympany. 4. Hyperresonance.

Correct Answer: 4 As a client ages, the function of the respiratory system becomes less efficient. The older adult's lungs lose their elasticity, muscles begin to weaken, and bones lose their density. Trapping of air in the alveoli will produce a hyperresonance sound upon percussion of the chest. Percussion over bone will yield flat sounds. Tympany is heard when percussion is performed over an air bubble. Percussion over solid organs or bones will yield a dull sound.

The nursing instructor is observing a student nurse assess the client's respiratory system. Which technique demonstrated by the student is the most appropriate? 1. From base to apices of lungs. 2. First up one side of the thorax, then up the other. 3. First down one side of the thorax, then down the other. 4. From side to side.

Correct Answer: 4 Auscultation should follow the same pattern as for percussion, from side to side, because comparison of sounds is an important step in respiratory assessment. Auscultate through the entire respiratory cycle, inspiration and expiration. The student nurse should ask the client to breathe deeply through the mouth each time the stethoscope is placed on the chest. The usual movement is from apices to the bases.

The nurse is assessing the client's respiratory system. Which method will result in the most accurate assessment of the client's respiratory rate? 1. The nurse should place a hand on the client's chest to count respirations accurately. 2. The nurse should inform the client that the nurse is counting the client's respirations. 3. The nurse should count only the respirations that are audible. 4. The nurse should count the respirations in an unobtrusive manner without informing the client.

Correct Answer: 4 If a client knows his respirations are being counted, it may alter the normal breathing pattern. Though laying a hand on the client's chest allows the nurse to feel the rise and fall of the chest, this may be considered an intrusive move and might increase the client's level of anxiety, which may affect the respiratory rate. The nurse should not inform the client about this portion of the assessment. Not all clients have audible respiratory cycles, and this would not be an effective method for accuracy.

The nurse is caring for an adolescent client who is hospitalized with asthma. Several peers are preparing to visit the client and have brought gifts. Which gift will the nurse prevent from being placed in the client's room? 1. Magazines. 2. Candy. 3. MP3 player. 4. Fresh flowers.

Correct Answer: 4 Limiting exposure to allergens, pollutants, and irritants in the client's environment is important to control and limit problems associated with respiratory health. Assessment must identify exposure to irritants such as dust, tobacco, smoke, pollen from trees or flowers, smog, asbestos, and vapors from household cleaners. The client's friends should be prevented from bringing anything in the room that may expose the client to anything that is known to be a trigger for the condition. Objects void of any irritant would be the best selection for a gift. Magazines, candy, and an MP3 player would all be appropriate gifts for this client.

The nurse is examining a client who is diagnosed with a fracture of one floating rib. Of the following ribs, which does the nurse suspect to be fractured? 1. 1. 2. 5. 3. 9. 4. 12.

Correct Answer: 4 The 12 pairs of ribs circle the body, form the lateral aspects of the thorax, and are attached to the vertebrae and sternum. Anteriorly, the first seven pairs of ribs articulate directly to the sternum. The cartilage of ribs 8, 9, and 10 articulates with the cartilage of rib 7, whereas the pairs of 11 and 12 are free floating and do not articulate anteriorly.

The nurse wants to assess the apex of a client's right lung. Which locations should the nurse place the stethoscope to assess this area on the client? 1. Intercostal space sixth rib near the sternum. 2. Intercostal space fourth rib near the axillary line. 3. Below the scapula. 4. Near the right clavicle.

Correct Answer: 4 The apex of each lung is slightly superior to the inner third of the clavicle whereas the base of each lung rests on the diaphragm.

The nurse is assessing the client's respiratory pattern and notes periods of deep breathing alternating with periods of apnea. When documenting this assessment finding, which term is the most appropriate for the nurse to use? 1. Tachypnea. 2. Obstructive breathing. 3. Hypoventilation. 4. Cheyne-Stokes.

Correct Answer: 4 The breathing described is a Cheyne-Stokes pattern. The client who has tachypnea exhibits rapid and shallow respirations. Clients with obstructive breathing have prolonged expirations. Hypoventilation is irregular and shallow breathing.

During the assessment of a client's respiratory system, the nurse determines that the client's expiration phase is the same length as the inspiration phase. The client's respiratory rate is 14 per minute. Which term will the nurse use to document this client finding in the medical record? 1. Obstructive breathing. 2. Bradypnea. 3. Respiratory distress. 4. Eupnea.

Correct Answer: 4 The finding describes eupnea, which is a normal breathing pattern. A client exhibiting obstructive breathing will have a prolonged expiration. Bradypnea is a term used to describe slow, regular respirations that are less than 10 per minute. These findings do not indicate that the client is experiencing respiratory distress.

While assessing the client, the nurse notes that the client has a productive cough. Based on this observation, which question is appropriate for the nurse to include in the focused interview? 1. "Have you been losing weight?" 2. "How long have you been sick?" 3. "Are you wheezing?" 4. "Are you coughing up any mucus or phlegm?"

Correct Answer: 4 The nurse must determine if the cough is productive or nonproductive. A moist cough is often associated with lung infections. The color and odor of any mucus or phlegm (sputum) is associated with specific diseases or problems.

The nurse is preparing to assess the client's respiratory system. Rank in order according to how the nurse should proceed. Response 1. Auscultation. Response 2. Inspection. Response 3. Percussion. Response 4. Client survey. Response 5. Palpation.

Correct Answer: 4, 2, 5, 3, 1 The physical assessment of the respiratory system follows an organized pattern. It begins with the client survey, then inspection of the anterior and posterior thorax. The assessment ends with palpation, percussion, and auscultation of the anterior thorax.

The nurse is conducting an assessment. Where is the right anterior axillary line (ALL) located?

Correct Answer: A Rationale 1: The anterior axillary line (AAL) is a line drawn parallel to the sternal line. There are right and left anterior axillary lines. The lines begin at the anterior fold of the axillae and descend along the anterior lateral aspects of the thoracic cage to the twelfth rib.

The client aspirated a pea during a meal. The healthcare provider notes that the pea is located in the bronchus. When educating the client regarding the location of the pea, which is the correct location for the nurse to use?

Correct Answer: A Rationale 1: The right main bronchus is shorter, wider, and more vertical than the left bronchus; therefore, aspirated objects are more likely to enter the right lung.

The nurse is preparing to auscultate the client's chest. Where will the nurse place the stethoscope to auscultate tracheal breath sounds?

Correct Answer: A Tracheal breath sounds are heard over the trachea when the client inhales and exhales. They are harsh and high-pitched.