Chapter 20 Prep U
You are caring for a client admitted with chronic bronchitis. The client is having difficulty breathing, and the family asks you what causes this difficulty. What would be your best response?
"Conditions such as chronic bronchitis cause thickening of the bronchial mucosa so it makes it harder to breathe." Explanation: Conditions that may alter bronchial diameter and affect airway resistance include contraction of bronchial smooth muscle (e.g., asthma); thickening of bronchial mucosa (e.g., chronic bronchitis); airway obstruction by mucus, a tumor, or a foreign body; and loss of lung elasticity (e.g., emphysema).
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.)
"Ventilation is the movement of air in and out of the respiratory tract." Explanation: Ventilation is the part of the respiration process that involves physical movement of air in and out of the respiratory tract.
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." Explanation: Ventilation is the part of the respiration process that involves physical movement of air in and out of the respiratory tract.
When the nurse is assessing the older adult patient, what gerontologic changes in the respiratory system should the nurse be aware of? (Select all that apply.)
- Increased presence of collagen in alveolar walls - Decreased presence of mucus - Decreased gag reflex Explanation: Age-related changes in the respiratory system include a decrease in mucus, decrease in gag reflex, increase in collagen in the alveolar walls of the lungs, and increase in alveolar duct diameter.
A nurse working in the radiology clinic is assisting with a client after an unusual arterial procedure. What assessment should the nurse notify the health care provider about?
- Previous history of lung disease in the patient or family - Occupational and environmental influences - Previous history of smoking Explanation: Risk factors associated with respiratory disease include smoking, exposure to allergens and environmental pollutants, and exposure to certain recreational and occupational hazards. Financial ability and social support are not pertinent to a chronic cough.
Your client is scheduled for a bronchoscopy to visualize the larynx, trachea, and bronchi. What precautions would you recommend to the client before the procedure?
Abstain from food for at least 6 hours before the procedure. Explanation: For at least 6 hours before bronchoscopy, the client must abstain from food or drink to decrease the risk of aspiration. Risk is increased because the client receives local anesthesia, which suppresses the reflexes to swallow, cough, and gag. The client receives medications before the procedure.
The nurse auscultated a patient's middle lobe of the lungs for abnormal breath sounds. To do this, the nurse placed the stethoscope on the:
Anterior surface of the right side of the chest, between the fourth and fifth rib. Explanation: The middle lobe of the lung is only found on the right side of the thorax and can only be assessed anteriorly. It is located at the fourth rib, at the right sternal border and extends to the fifth rib, in the midaxillary line.
The nurse is caring for a client diagnosed with pneumonia. The nurse assesses the client for tactile fremitus by completing which action?
Asking the client to repeat "ninety-nine" as the nurse's hands move down the client's thorax Explanation: While the nurse is assessing for tactile fremitus, the client is asked to repeat "ninety-nine" or "one, two, three," or "eee, eee, eee" as the nurse's hands move down the client's thorax. Vibrations are detected with the palmar surfaces of the fingers and hands, or the ulnar aspect of the extended hands, on the thorax. The hand(s) are moved in sequence down the thorax, and corresponding areas of the thorax are compared. Asking the client to say "one, two, three" while auscultating the lungs is not the proper technique to assess for tactile fremitus
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 Explanation: The presence of both inspiratory and expiratory wheezing usually signifies asthma if the individual does not have heart failure. Sudden dyspnea is an indicator of the other choices.
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 Explanation: Cyanosis, a bluish coloring of the skin, is a very late indicator of hypoxia. The presence or absence of cyanosis is determined by the amount of unoxygenated hemoglobin in the blood. Cyanosis appears when there is at least 5 g/dL of unoxygenated hemoglobin.
The nurse is completing a physical assessment of a client's trachea. The nurse inspects and palpates the trachea for
Deviation from the midline. Explanation: During the physical examination, the nurse must inspect and gently palpate the trachea to assess for placement and deviation from the midline. The trachea is normally in the midline as it enters the thoracic inlet behind the sternum, but it may be deviated by a mass in the neck or mediastinum. Pulmonary disorders, such as a pneumothorax or pleural effusion, may also displace the trachea.
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 Explanation: Pulse oximetry is a noninvasive method of monitoring oxygen saturation of hemoglobin. A probe is placed on the fingertip, forehead, earlobe, or bridge of nose.
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 Explanation: Nurses must determine if the client has any allergies, particularly to iodine, shellfish, or contrast dye. During the procedure, the nurse should check for signs and symptoms of allergic reactions to the contrast medium, such as itching, hives, or difficulty in breathing
High or increased compliance occurs in which disease process?
Emphysema Explanation: High or increased compliance occurs if the lungs have lost their elasticity and the thorax is overdistended, as in emphysema. Conditions associated with decreased compliance include pneumothorax, pleural effusion, and acute respiratory distress syndrome (ARDS).
A client with sinus congestion complains of discomfort when the nurse is palpating the supraorbital ridges. What sinus is the client referring?
Frontal Explanation: The nurse may palpate the frontal and maxillary sinuses for tenderness. Using the thumbs, the nurse applies gentle pressure in an upward fashion at the supraorbital ridges (frontal sinuses) and in the cheek area adjacent to the nose (maxillary sinuses).
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" Explanation: 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
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 Explanation: Airflow is decreased with atelectasis, which is a bronchial obstruction from collapsed lung tissue. If there is an obstruction, there is limited or no gas exchange in this area. Impaired gas exchange is thus the most likely nursing diagnosis with atelectasis.
What would the instructor tell the students purulent fluid indicates?
Infection Explanation: A small amount of fluid lies between the visceral and parietal pleurae. When excess fluid or air accumulates, the physician aspirates it from the pleural space by inserting a needle into the chest wall. This procedure, called thoracentesis, is performed with local anesthesia. Thoracentesis also may be used to obtain a sample of pleural fluid or a biopsy specimen from the pleural wall for diagnostic purposes such as a culture, sensitivity, or microscopic examination. Purulent fluid is the recommended diagnosis for infection. Serous fluid may be associated with cancer, inflammatory conditions, or heart failure.
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 Explanation: During lung scans, a radioactive contrast medium is administered intravenously for the perfusion scan. Before the perfusion scan, nurses must assess the client to check for allergies to iodine. Laryngoscopy determines inflammation.
A client has just undergone bronchoscopy. Which nursing assessment is most important at this time?
Level of consciousness Explanation: Following bronchoscopy, level of consciousness is the most important assessment because changes in the client's level of consciousness may alert the nurse to serious neurologic problems. Anxiety, swallowing reflex, and voice quality are important, but don't take precedence at this time
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 Explanation: To palpate the maxillary sinuses, the nurse should apply gentle pressure in the cheek area below the eyes, adjacent to the nose.
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 Explanation: 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).
What is the primary function of the larynx?
Producing sound Explanation: The larynx, or voice box, is a cartilaginous framework between the pharynx and trachea. Its primary function is to produce sound. While the larynx assists in protecting the lower airway, this is mainly the function of the epiglottis.
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 Explanation: Pulse oximetry is a noninvasive method to determine arterial oxygen saturation. Normal values are 95% and above.
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?
Sitting on the edge of the bed Explanation: 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. Other positions in which the client could be placed include straddling a chair with arms and head resting on the back of the chair, or lying on the unaffected side with the head of the bed elevated 30 to 45 degrees (if the client is unable to assume a sitting position).
In which position should the client be placed for a thoracentesis?
Sitting on the edge of the bed Explanation: If possible, 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. Other positions in which the client could be placed include straddling a chair with the arms and head resting on the back of the chair, or lying on the unaffected side with the head of the bed elevated 30 to 45 degrees (if the client is unable to assume a sitting position).
The nurse is admitting a client who just had a bronchoscopy. Which assessment should be the nurse's priority?
Swallow reflex Explanation: The physician sprays a local anesthetic into the client's throat before performing a bronchoscopy. The nurse must assess the swallow reflex when the client returns to the unit and before giving him anything by mouth
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. Explanation: When completing a procedure which sends a scope down the throat, the gag reflex is anesthetized to reduce discomfort. Upon returning to the nursing unit, the gag reflex must be assessed before providing any food or fluids to the client
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 Explanation: The inspiratory and expiratory centers in the medulla oblongata and pons control the rate and depth of ventilation. When injury occurs or increased intracranial pressure results, respirations are slowed. The frontal lobe completes executive functions and cognition
Which term refers to the volume of air inhaled or exhaled during each respiratory cycle?
Tidal volume Explanation: Tidal volume refers to the volume of air inhaled or exhaled during each respiratory cycle when breathing normally
The amount of air inspired and expired with each breath is called:
Tidal volume Explanation: Tidal volume is the amount of air inspired and expired with each breath. Residual volume is the amount of air remaining in the lungs after forcibly exhaling.
Which hollow tube transports air from the laryngeal pharynx to the bronchi?
Trachea Explanation: The trachea is a hollow tube composed of smooth muscle and supported by C-shaped cartilage. The trachea transports air from the laryngeal pharynx to the bronchi and lungs.
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. Explanation: A high ventilation-perfusion rate means that ventilation exceeds perfusion, causing dead space. The alveoli do not have an adequate blood supply for gas exchange to occur. This is characteristic of a variety of disorders, including pulmonary emboli, pulmonary infarction, and cardiogenic shock.
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 Explanation: Vesicular breath sounds are heard over the entire lung field except the upper sternum and between the scapulae.
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. Explanation: A physician usually performs a thoracentesis when the client is sitting in a chair or on the edge of the bed, with the legs supported and the arms folded and resting on a pillow or on the bedside table.
The nurse auscultates lung sounds that are harsh and cracking, sounding like two pieces of leather being rubbed together. The nurse would be correct in documenting this finding as
pleural friction rub. Explanation: A pleural friction rub is heard secondary to inflammation and loss of lubricating pleural fluid. Crackles are soft, high-pitched, discontinuous popping sounds that occur during inspiration. Sonorous wheezes are deep, low-pitched rumbling sounds heard primarily during expiration. Sibilant wheezes are continuous, musical, high-pitched, whistle-like sounds heard during inspiration and expiration.