Chapter 20 PrepU (Assessment of respiratory function)

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?

Angiotensin converting enzyme (ACE) inhibitors Common causes of cough include asthma, gastrointestinal reflux disease, infection, aspiration, and side effects of medications, such as angiotensin converting enzyme (ACE) inhibitors. The other medications listed are not associated with causing a cough.

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

Count the rate of respirations. Observing the rate and depth of respiration is an important aspect of a nursing assessment. The normal adult resting respiratory rate is 12 to 18 breaths per minute. Tachypnea is rapid breathing with a rate greater than 24 breaths per minute. An increase in the rate of respirations needs further investigation and must be reported.

Which is an age-related change associated with the respiratory system?

Decreased size of the airway Age-related changes that occur in the respiratory system are a decrease in the size of the airway, decreased chest muscle mass, increased thickening of the alveolar membranes, and decreased elasticity of the alveolar sacs.

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 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. 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.

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. 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.

The client has just had an invasive procedure to assess the respiratory system. What does the nurse know should be assessed on this client?

Respiratory distress After invasive procedures, the nurse must carefully check for signs of respiratory distress and blood-streaked sputum. Masses in the pleural space are a condition that affects fremitus. General examination of overall health and condition includes assessing the consciousness of a client.

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

Sitting on the edge of the bed 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 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. 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. The client may need assistance following the procedure for activity and ambulation but this is not restricted in the post procedure period.

What is the difference between respiration and ventilation?

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

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" 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. The client will feel pressure when the catheter is inserted. The client does not typically feel light-headed or nauseated during this 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. The reading is referred to as SpO2. A probe or sensor is attached to the fingertip, forehead, earlobe, or bridge of the nose. Values less than 85% indicate that the tissues are not receiving enough oxygen. SpO2 values obtained by pulse oximetry are unreliable in states of low perfusion such as hypothermia.

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?

Absent distal pulses When monitoring clients after a pulmonary angiography, 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.

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 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 assesses for anterior respiratory excursion by placing the thumbs along the costal margin of the chest wall and instructing the client to inhale deeply. The nurse assesses for diaphragmatic excursion by instructing the client to take a deep breath and hold it while the diaphragm is percussed.

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 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.

Which is a deformity of the chest that occurs as a result of overinflation of the lungs?

Barrel chest A barrel chest occurs as a result of overinflation of the lungs. The anteroposterior diameter of the thorax increases. Funnel chest occurs when a depression occurs in the lower portion of the sternum, which may result in murmurs. Pigeon chest occurs as a result of displacement of the sternum, resulting in an increase in the anteroposterior diameter. Kyphoscoliosis is characterized by elevation of the scapula and a corresponding S-shaped spine. This deformity limits lung expansion within the thorax.

What finding by the nurse may indicate that the client has chronic hypoxia?

Clubbing of the fingers Clubbing of the fingers is a change in the normal nail bed. It appears as sponginess of the nail bed and loss of the nail bed angle. It is a sign of lung disease that is found in patients with chronic hypoxic conditions, chronic lung infections, or malignancies of the lung. The other signs listed may represent only a temporary hypoxia.

The nurse is assessing the lungs of a patient diagnosed with pulmonary edema. Which of the following would be expected upon auscultation?

Crackles at lung bases A patient with pulmonary edema would be expected to have crackles in the lung bases, and possible wheezes. Egophony may occur in patients diagnosed with pleural effusion. Absent breath sounds occurs in pneumothorax. Bronchial breath sounds occur in consolidation, such as pneumonia.

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.

Diaphragm contracts and elongates the chest cavity. The diaphragm contracts during inspiration and pulls the lungs in a downward and forward direction. The abdomen appears to enlarge because the abdominal contents are being compressed by the diaphragm. With inspiration, the diaphragmatic pull elongates the chest cavity, and the external intercostal muscles (located between and along the lower borders of the ribs) contract to raise the ribs, which expands the anteroposterior diameter. The effect of these movements is to decrease the intrapulmonary pressure.

A client with sinus congestion complains of discomfort when the nurse is palpating the supraorbital ridges. What sinus is the client referring?

Frontal 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). The ethmoidal sinuses are located between the nose and eyes. The sphenoidal sinuses are behind the nose between the eyes.

What would the instructor tell the students purulent fluid indicates?

Infection 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.

A client has a nursing diagnosis of "ineffective airway clearance" as a result of excessive secretions. An appropriate outcome for this client would be which of the following?

Lungs are clear on auscultation. Assessment of lung sounds includes auscultation for airflow through the bronchial tree. The nurse evaluates for fluid or solid obstruction in the lung. When airflow is decreased, as with fluid or secretions, adventitious sounds may be auscultated. Often crackles are heard with fluid in the airways.

Upon palpation of the sinus area, what would the nurse identify as a normal finding?

No sensation during palpation Sinus assessment involves using the thumbs to apply gentle pressure in an upward fashion at the sinuses. Tenderness suggests inflammation. The sinuses can be inspected by transillumination, where a light is passed through the sinuses. If the light fails to penetrate, the cavity contains fluid.

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?

Normal bronchovesicular sounds 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. The other choices do not match type of breath sound for the location in question.

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 To palpate the maxillary sinuses, the nurse should apply gentle pressure in the cheek area below the eyes, adjacent to the nose.

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

Orthopnea Orthopnea is the inability to breathe easily except when upright. This positioning can mean while in bed and propped with a pillow or sitting in a chair. If a client cannot breathe easily while lying down, there is an element of respiratory distress.

A patient comes to the emergency department complaining of a knifelike pain when taking a deep breath. What does this type of pain likely indicate to the nurse?

Pleurisy

A patient comes to the emergency department complaining of a knifelike pain when taking a deep breath. What does this type of pain likely indicate to the nurse?

Pleurisy Pleuritic pain from irritation of the parietal pleura is sharp and seems to "catch" on inspiration; patients often describe it as being "like the stabbing of a knife." In carcinoma, the pain may be dull and persistent because the cancer has invaded the chest wall, mediastinum, or spine.

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

Rhonchi Rhonchi or sonorous wheezes are deep, low-pitched, rumbling sounds heard usually on expiration. The etiology of rhonchi is associated with chronic bronchitis. Crackles are soft, high-pitched sounds. Pleural friction rub is a creaking or grating sound not affected by coughing. Bronchial sounds are relatively high-pitched sounds.

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 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).

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

Swallow reflex 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 nurse should also assess for medication allergies, carotid pulse, and deep breathing, but they aren't the priority at this time.

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 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. The central sulcus is a fold in the cerebral cortex called the central fissure. The Wernicke's area is the area linked to speech.

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

Use of accessory muscles 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.

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. 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.

What is the purpose of the vascular and ciliated mucous lining of the nasal cavities?

Warm and humidify inspired air The vascular and ciliated mucous lining of the nasal cavities warms and humidifies inspired air. It is the function of the cilia alone to move mucus in the nasal cavities and filter the inspired air.

While auscultating the lungs of a client with asthma, the nurse hears a continuous, high-pitched whistling sound on expiration. The nurse will document this sound as which of the following?

Wheezes Wheezes, usually heard on expiration, are continuous, musical, high pitched, and whistle-like sounds caused by air passing through narrowed airways. Often, wheezes are associated with asthma.

A client is chronically short of breath and yet has normal lung ventilation, clear lungs, and an arterial oxygen saturation SaO2 of 96% or better. The client most likely has:

a possible hematologic problem. SaO2 is the degree to which hemoglobin (Hb) is saturated with oxygen. It doesn't indicate the client's overall Hb adequacy. Thus, an individual with a subnormal Hb level could have normal SaO2 and still be short of breath, indicating a possible hematologic problem. Poor peripheral perfusion would cause subnormal SaO2. There isn't enough data to assume that the client's problem is psychosomatic. If the problem were left-sided heart failure, the client would exhibit pulmonary crackles.

Pink, frothy sputum may be an indication of

pulmonary edema. Profuse frothy, pink material, often welling up into the throat, may indicate pulmonary edema. Foul-smelling sputum and bad breath may indicate a lung abscess, bronchiectasis, or an infection caused by fusospirochetal or other anaerobic organisms.

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

tidal volume Tidal volume is the volume of air inhaled and exhaled with each breath. Residual volume is the volume of air remaining in the lungs after a maximum expiration. Vital capacity is the maximum volume of air exhaled from the point of maximum inspiration. Expiratory reserve volume is the maximum volume of air that can be exhaled after a normal inhalation.

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. 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. Typically, atropine is given to dry secretions and a sedative or narcotic is given to depress the vagus nerve. The client may need to hold his or her breath for short periods during lung scans and for bronchoscopy.

Which is a true statement regarding air pressure variances?

Air is drawn through the trachea and bronchi into the alveoli during inspiration. Air flows from a region of higher pressure to a region of lower pressure. During inspiration, movement of the diaphragm and other muscles of respiration enlarge the thoracic cavity, thereby lowering the pressure inside the thorax to a level below that of atmospheric pressure.

A client with newly diagnosed emphysema is admitted to the medical-surgical unit for evaluation. Which does the nurse recognize as a deformity of the chest wall that occurs as a result of overinflation of the lungs in this client population?

Barrel chest A barrel chest occurs as a result of over inflation of the lungs. The anteroposterior diameter of the thorax increases. Barrel chest occurs with aging and is a hallmark sign of emphysema and chronic obstructive pulmonary disease (COPD). In a client with emphysema, the ribs are more widely spaced and the intercostal spaces tend to bulge upon expiration. Funnel chest occurs when a depression occurs in the lower portion of the sternum, which may result in murmurs. Pigeon chest occurs as a result of displacement of the sternum, resulting in an increase in the anteroposterior diameter. Kyphoscoliosis is characterized by elevation of the scapula and a corresponding S-shaped spine. This deformity limits lung expansion within the thorax.

The nurse is assessing a patient in respiratory failure. What finding is a late indicator of hypoxia?

Cyanosis 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 assessing a patient in respiratory failure. What is a late indicator of hypoxia?

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

Bradypnea is associated with which condition?

Increased intracranial pressure Bradypnea is associated with increased intracranial pressure, brain injury, and drug overdose. Tachypnea is commonly seen in clients with pneumonia, pulmonary edema, and metabolic acidosis.

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 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. Dysrhythmias and bleeding are possible complications of mediastinoscopy.

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

Kussmaul respirations Kussmaul respirations are seen in patients with diabetic ketoacidosis. In Cheyne-Stokes respiration, rate and depth increase, then decrease until apnea occurs. 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 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 can view soft tissues and can help stage cancers. MRI uses magnetic fields and radiofrequency signals to produce a detailed diagnostic image. MRI can visualize soft tissues, characterize nodules, and help stage carcinomas. The other options describe different studies.

What is the primary function of the larynx?

Producing sound 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. Facilitating coughing is a secondary function of the larynx. Preventing infection is the main function of the tonsils and adenoids.

The clinical finding of pink, frothy sputum may be an indication of which condition?

Pulmonary edema Profuse frothy, pink material, often welling up into the throat, may indicate pulmonary edema. Foul-smelling sputum and bad breath may indicate a lung abscess, bronchiectasis, or an infection caused by fusospirochetal or other anaerobic organisms.

A nurse is caring for a client after a lung biopsy. Which assessment finding requires immediate intervention?

Respiratory rate of 44 breaths/minute A respiratory rate of 44 breaths/minute is significant and requires immediate intervention. The client may be experiencing postoperative complications, such as pneumothorax or bleeding. An oxygen saturation level of 96% on 3 L of oxygen, a pain level of 7 out of 10 that decreases with pain medication, and dozing when left alone are normal and don't require further intervention.

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?

Take deep breaths and cough forcefully. Taking deep breaths moves air around the sputum and coughing forcefully moves the sputum up the respiratory tract. Once in the pharynx, the sputum can be expectorated into a specimen container. Producing a gag reflex elicits stomach contents and not respiratory sputum. Dilute and thinned secretions are not helpful in aiding expectoration. A sputum culture is not a component of oral secretions.

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?

They can be heard during inspiration and expiration. 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. The crackling or grating sounds heard during inspiration or expiration are friction rubs. They occur when the pleural surfaces are inflamed.

A nurse is assessing a client's respiratory system. Which alveolar cells secrete surfactant to reduce lung surface tension?

Type II There are three types of alveolar cells. Type I and type II cells make up the alveolar epithelium. Type I cells account for 95% of the alveolar surface area and serve as a barrier between the air and the alveolar surface; type II cells account for only 5% of this area but are responsible for producing type I cells and surfactant. Surfactant reduces surface tension, thereby improving overall lung function. Alveolar macrophages, the third type of alveolar cells, are phagocytic cells that ingest foreign matter and, as a result, provide an important defense mechanism. Type IV is not a category of alveolar cells.

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 Sibilant wheezes are continuous, musical, high-pitched, whistle-like sounds heard during inspiration and expiration caused by air passing through narrowed or partially obstructed airways; they may clear with coughing. Crackles, formerly called rales, are soft, high-pitched, discontinuous popping sounds that occur during inspiration (while usually heard on inspiration, they may also be heard on expiration); they may or may not be cleared by coughing. Rhonchi, or sonorous wheezes, are deep, low-pitched rumbling sounds heard primarily during expiration; they are caused by air moving through narrowed tracheobronchial passages.

Which term will the nurse use to document the inability of a client to breathe easily unless positioned upright?

orthopnea Orthopnea is the term used to describe a client's inability to breathe easily except in an upright position. Orthopnea may occur in clients with heart disease and, occasionally, in clients with COPD. Clients with orthopnea are placed in a high Fowler's position to facilitate breathing. Dyspnea refers to labored breathing or shortness of breath. Hemoptysis refers to expectoration of blood from the respiratory tract. Hypoxemia refers to low oxygen levels in the blood.

Why is it important for a nurse to provide required information and appropriate explanations of diagnostic procedures to patients with respiratory disorders?

Manage decreased energy levels In addition to the nursing management of individual tests, patients with respiratory disorders require informative and appropriate explanations of any diagnostic procedures they will experience. Nurses must remember that for many of these patients, breathing may in some way be compromised. Energy levels may be decreased. For that reason, explanations should be brief yet complete and may need to be repeated later after a rest period. The nurse must also ensure adequate rest periods before and after the procedures. After invasive procedures, the nurse must carefully assess for signs of respiratory distress.

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

Pleurisy 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." Chest pain associated with the other conditions may be dull, aching, and persistent.

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 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. All other options vary in amount of time and patient participation in determining further information regarding the respiratory system.

The instructor of the pre-nursing physiology class is explaining respiration to the class. What does the instructor explain is the main function of respiration?

To exchange oxygen and CO2 between the atmospheric air and the blood and between the blood and the cells The main function of the respiratory system is to exchange oxygen and CO2 between the atmospheric air and the blood and between the blood and the cells. This process is called respiration. The purpose of respiration is not to move any gas into the expired air; retained air is simply a distractor for this question; and atmospheric air is not exchanged between the blood and the cells.

A thoracentesis is performed to obtain a sample of pleural fluid or a biopsy specimen from the pleural wall for diagnostic purposes. What does bloody fluid results indicate?

Trauma A thoracentesis may be performed to obtain a sample of pleural fluid or to biopsy a specimen from the pleural wall for diagnostic purposes. The fluid, which may be clear, serous, bloody, or purulent, provides clues to the pathology. Bloody fluid may indicate trauma, whereas purulent fluid usually indicates an infection and serous fluid indicates malignancy or heart failure. Pneumothorax, tension pneumothorax, subcutaneous emphysema, and pyogenic infection are complications of a thoracentesis. Pulmonary edema or cardiac distress can occur after a sudden shift in mediastinal contents when large amounts of fluid are aspirated.

A nurse is discussing squamous epithelial cells lining each alveolus, which consist of different types of cells. Which type of alveolar cells produce surfactant?

Type II cells There are three types of alveolar cells. Type I and type II cells make up the alveolar epithelium. Type I cells account for 95% of the alveolar surface area and serve as a barrier between the air and the alveolar surface; type II cells account for only 5% of this area, but are responsible for producing type I cells and surfactant. Surfactant reduces surface tension, thereby improving overall lung function. Alveolar macrophages, the third type of alveolar cells, are phagocytic cells that ingest foreign matter and, as a result, provide an important defense mechanism. The epithelium of the alveoli does not contain Type IV cells.

Understanding pulmonary physiology, what characteristic would the nurse expect to result in decreased gas exchange in older adults?

alveolar walls containing fewer capillaries Although the number of alveoli remains stable with age, the alveolar walls become thinner and contain fewer capillaries, resulting in decreased gas exchange. The lungs also lose elasticity and become stiffer. Elasticity of lungs does not increase with age, and the number of alveoli does not decrease with age.

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?

eustachian tubes The nasopharynx contains the adenoids and openings of the eustachian tubes. The eustachian tubes connect the pharynx to the middle ear and are the means by which upper respiratory infections spread to the middle ear. The client's infection is not caused by genetics. The oropharynx contains the tongue. The epiglottis closes during swallowing and relaxes during respiration.

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 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). Dyspnea (subjective feeling of difficult or labored breathing, breathlessness, shortness of breath) is a multidimensional symptom common to many pulmonary and cardiac disorders, particularly when there is decreased lung compliance or increased airway resistance. Tachypnea is abnormally rapid respirations. Bradypnea is abnormally slow respirations.

The amount of air inspired and expired with each breath is called:

tidal volume. 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. Vital capacity is the maximum amount of air that can be moved out of the lungs after maximal inspiration and expiration. Dead-space volume is the amount of air remaining in the upper airways that never reaches the alveoli. In pathologic conditions, dead space may also exist in the lower airways.

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

tidal volume. Tidal volume is the volume of air inhaled and exhaled with each breath. Residual volume is the volume of air remaining in the lungs after a maximum expiration. Vital capacity is the maximum volume of air exhaled from the point of maximum inspiration. Expiratory reserve volume is the maximum volume of air that can be exhaled after a normal inhalation.