Chapter 27 - Assessment of the Respiratory System

A nurse plans care for a client who is at high risk for a pulmonary infection. Which interventions should the nurse include in this client's plan of care? (Select all that apply.)

- Encourage deep breathing and coughing. - Ambulate the client three times each day. - Provide a diet high in protein and vitamins. Regular pulmonary hygiene and activities to maintain health and fitness help to maximize functioning of the respiratory system and prevent infection.

A nurse observes that a client's anteroposterior (AP) chest diameter is the same as the lateral chest diameter. Which question should the nurse ask the client in response to this finding?

"Do you have any chronic breathing problems?" The normal chest has a lateral diameter that is twice as large as the AP diameter. When the AP diameter approaches or exceeds the lateral diameter, the client is said to have a barrel chest. Most commonly, barrel chest occurs as a result of a long-term chronic airflow limitation problem, such as chronic obstructive pulmonary disease or severe chronic asthma. It can also be seen in people who have lived at a high altitude for many years.

A nurse teaches a client who is interested in smoking cessation. Which statements should the nurse include in this client's teaching? (Select all that apply.)

"Find an activity that you enjoy and will keep your hands busy." "Drink at least eight glasses of water each day." "Make a list of reasons you want to stop smoking." The nurse should teach a client who is interested in smoking cessation to find an activity that keeps the hands busy, to keep healthy snacks on hand to nibble on, to drink at least 8 glasses of water each day, and to make a list of reasons for quitting smoking.

A nurse collaborates with a respiratory therapist to complete pulmonary function tests (PFTs) for a client. Which statements should the nurse include in communications with the respiratory therapist prior to the tests? (Select all that apply.)

"I held the client's morning bronchodilator medication." "I advised the client not to smoke for 6 hours prior to the test." "The client is alert and can follow your commands." To ensure the PFTs are accurate, the therapist needs to know that no bronchodilators have been administered in the past 4 to 6 hours, the client did not smoke within 6 to 8 hours prior to the test, and the client can follow basic commands, including different breathing maneuvers.

A nurse teaches a client who is prescribed nicotine replacement therapy. Which statement should the nurse include in this client's teaching?

"Smoking while taking this medication will increase your risk of a stroke." Clients who smoke while using drugs for nicotine replacement therapy increase the risk of stroke and heart attack. Nurses should teach clients not to smoke while taking this drug.

While obtaining a client's health history, the client states, "I am allergic to avocados." Which responses by the nurse are best? (Select all that apply.)

"What response do you have when you eat avocados?" "I will document this in your record so all of your providers will know." "Have you ever been treated for this allergic reaction?" Nurses should assess clients who have allergies for the specific cause, treatment, and response to treatment. The nurse should also document the allergies in a prominent place in the client's medical record. The nurse should collaborate with food services to ensure no avocados are placed on the client's meal trays.

A nurse assesses a 66-year-old client who is attempting to quit smoking. The client states, "I started smoking at age 16, and smoked one pack each day until 10 years ago. Then I decreased to a half of a pack per day." How many pack-years should the nurse document for this client? (Record your answer using a whole number.) ___ pack-years

45 pack-years 66 (current age) - 16 (year started smoking) = 50 years of smoking. (40 years ´ 1 pack per day) + (10 years ´ 0.5 pack per day) = 45 pack-years.

A client with asthma reports shortness of breath. What is the nurse assessing when auscultating this client's chest?

Adventitious breath sounds Adventitious sounds are additional breath sounds superimposed on normal sounds. They indicate pathologic changes in the lung.

A nurse is assessing a client who is recovering from a lung biopsy. Which assessment finding requires immediate action?

Absent breath sounds Absent breath sounds may indicate that the client has a pneumothorax, a serious complication after a needle biopsy or open lung biopsy.

A client who had an earlier bronchoscopy has the following vital signs: heart rate 132 beats/min, respiratory rate 26 breaths/min, and blood pressure 98/50 mm Hg. The client is anxious and his skin is cyanotic. What is the nurse's first action?

Administer oxygen. Administering oxygen and reassessing vital signs to observe for improvement is the first action. Administration of oxygen by itself may help relieve the client's anxiety.

Where does gas exchange occur?

Alveolus The alveolus is the structural unit of the lung where gas exchange occurs.

A nurse cares for a client who had a bronchoscopy 2 hours ago. The client asks for a drink of water. Which action should the nurse take next?

Assess the client's gag reflex before giving any food or water. The topical anesthetic used during the procedure will have affected the client's gag reflex. Before allowing the client anything to eat or drink, the nurse must check for the return of this reflex.

A nurse is caring for an older adult client who has a pulmonary infection. Which action should the nurse take first?

Assess the client's level of consciousness. Assessing the client's level of consciousness will be most important because it will show how the client is responding to the presence of the infection.

A nurse plans care for a client who is experiencing dyspnea and must stop multiple times when climbing a flight of stairs. Which intervention should the nurse include in this client's plan of care?

Assistance with activities of daily living A client with dyspnea and difficulty completing activities such as climbing a flight of stairs has class III dyspnea. The nurse should provide assistance with activities of daily living. These clients should be encouraged to participate in activities as tolerated. They should not be on complete bedrest, may not be able to tolerate daily physical therapy, and only need oxygen if hypoxia is present.

Which assessment finding is of greatest concern in a client with emphysema?

Bronchial breath sounds heard at the bases Bronchial breath sounds are not normally heard in the periphery and may indicate increased lung density, as in a tumor or an infective process such as pneumonia.

Which component of a client's family history is of particular importance to the home health nurse who is assessing a new client with asthma?

Brother is allergic to peanuts. Clients with asthma often have a family history of allergies; it will be important to assess whether this client has any allergies that may serve as triggers for an asthma attack.

The nurse is performing a client assessment for the client's potential employer. The client reports dyspnea when climbing stairs but is not dyspneic at rest. Which dyspnea classification does the nurse assign to this client in the report to the employer?

Class II, can perform desk job This client is dyspneic when climbing stairs or walking on an incline, but not on level walking; therefore, this client is considered class II and employable only for a sedentary job or under special circumstances.

A nurse assesses a client after an open lung biopsy. Which assessment finding is matched with the correct intervention?

Client has reduced breath sounds. - Nurse calls physician immediately. A potentially serious complication after biopsy is pneumothorax, which is indicated by decreased or absent breath sounds. The physician needs to be notified immediately.

The nurse is working in an urgent care clinic. Which client needs to be evaluated first by the nurse?

Client who is speaking in three-word sentences and has an SpO2 of 90% by pulse oximetry A client should be able to speak in sentences of more than three words, and an SpO2 of 90% indicates hypoxemia that requires intervention on the part of the nurse.

Four clients are sent back to the emergency department from triage at the same time. Which client requires the nurse's immediate attention?

Client with acute allergic reaction An acute allergic reaction can lead to immediate respiratory distress; this is an emergent situation that requires the immediate attention of the nurse.

The RN has received report about all of these clients. Which client needs the most immediate assessment?

Client with acute asthma who has an oxygen saturation of 89% by pulse oximetry An oxygen saturation level less than 91% indicates hypoxemia and requires immediate assessment and intervention to improve blood and tissue oxygenation.

The home health nurse is assigned to visit all of these clients when a change in agency staffing requires that one of the clients be rescheduled for a visit on the following day. Which client would be best to reschedule?

Client with emphysema who has been on home oxygen for a month and has SpO2 levels of 91% to 93% The client with emphysema has an appropriate SpO2 for home oxygen use.

Which client does the charge nurse on the medical unit assign to an RN who has floated from the postanesthesia care unit (PACU)?

Client with pleural effusion who has had 1200 mL removed by thoracentesis A nurse working in the PACU would be familiar with assessing vital signs and respiratory status after procedures such as thoracentesis.

A client is admitted to the surgical floor with chest pain, shortness of breath, and hypoxemia after having a knee replacement. What diagnostic test does the nurse expect to help confirm the diagnosis?

Computed tomography (CT) scan CT scans, especially spiral or helical CT scans, with injected contrast can detect pulmonary emboli.

The nurse auscultates popping, discontinuous sounds over the client's anterior chest. How does the nurse classify these sounds?

Crackles Crackles are described as a popping, discontinuous sound caused by air moving into previously deflated airways. The airways have been deflated due to the presence of fluids in the lungs, and crackles should be considered to be a sign of fluid overload.

When auscultating the client's breath sounds, the nurse hears soft rustling sounds at the lung edges. What is the nurse's best action?

Document the finding as the only action. Rationale: The sounds described are vesicular sounds, which are normally heard at the peripheral lung fields where air flows through smaller bronchioles and alveoli. Thus, this is a normal finding that does not require any action other than documentation.

A nurse auscultates a harsh hollow sound over a client's trachea and larynx. Which action should the nurse take first?

Document the findings. Bronchial breath sounds, including harsh, hollow, tubular, and blowing sounds, are a normal finding over the trachea and larynx. The nurse should document this finding.

For which problem does the nurse assess the client who cannot breathe through the nose because of a severe septal deviation?

Dry respiratory tract membranes Rationale: When inspired air passes through the nose, it is filtered, warmed, and humidified. When a person is unable to breathe through the nose because of an anatomical obstruction, he or she is at risk for excessive drying of the respiratory mucous membranes.

A client is admitted to the medical floor with a new diagnosis of lung cancer. How does the nurse assist the client initially with the anxiety associated with the new diagnosis?

Encourage the client to ask questions and verbalize concerns. Anxiety causes increased oxygen consumption, and oxygen availability is limited in lung cancer; the availability of the nurse to answer questions and listen to the client's concerns will decrease anxiety.

In assessing the client's respiratory status, arterial blood gas (ABG) test results reveal pH of 7.50, PaO2 of 99 mm Hg, PaCO2 of 29 mm Hg, and HCO3- of 22 mEq/L. What action does the nurse need to take first?

Encourage the client to slow his breathing rate. The ABGs indicate respiratory alkalosis, which is commonly caused by hyperventilation; encouraging the client to slow down his breathing rate may help the client return to normal breathing and may correct this abnormality.

Which nursing intervention is the priority in preparing a client for pulmonary function testing (PFT)?

Ensure no smoking 6 hours before the test. If the client has been smoking, this may alter parts of the PFT (diffusing capacity [DLCO]), yielding inaccurate results. Administering bronchodilators is not indicated for PFT, but they may be withheld for 4 to 6 hours before the test.

People involved in which occupations or activities are encouraged to wear masks and to have adequate ventilation? (Select all that apply.)

Furniture refinishers Potters Coal miners Bakers Being exposed to flour as a baker for prolonged periods of time may cause a condition called occupational asthma. Coal miners are at risk to develop pneumoconiosis as the result of inhalation of coal dust. Owing to the chemicals used to refinish furniture (paint strippers, solvents), masks and adequate ventilation are essential for furniture refinishers. One of the main solvents involved will metabolize in the body to carbon monoxide and will impair the ability of the tissue to extract oxygen. Silicosis or inhalation of silica dust is a hazard for professional and recreational potters.

What is the term for the opening between the vocal cords?

Glottis The glottis is the opening of the vocal cords into which the endotracheal tube is passed during intubation for surgery.

The client returns to the medical unit after a therapeutic bronchoscopy. Which intervention does the nurse apply first?

Implement nothing-by-mouth (NPO) status. Until the client has a gag reflex and is fully alert, he or she should be maintained on NPO status to prevent aspiration.

In the older adult client, which respiratory change requires no further assessment by the nurse?

Increased anteroposterior (AP) diameter Increased AP diameter is normal with aging. Increased respiratory rate is not a normal finding with aging and may be an indication of pain or infection; it needs to be evaluated further by the nurse.

A nurse obtains the health history of a client who is recently diagnosed with lung cancer and identifies that the client has a 60-pack-year smoking history. Which action is most important for the nurse to take when interviewing this client?

Maintain a nonjudgmental attitude to avoid causing the client to feel guilty. Because the client may have guilt or denial about this habit, assume a nonjudgmental attitude during the interview. This will encourage the client to be honest about the exposure.

A client has returned to the postanesthesia care unit (PACU) after a bronchoscopy. Which nursing task is best for the charge nurse to delegate to the experienced nursing assistant working in the PACU?

Monitor blood pressure and pulse. A nursing assistant working in the PACU would have experience in taking client vital signs after the client has had conscious sedation or anesthesia. Evaluating breath sounds and gag reflex and determining level of consciousness require the skill and knowledge of a higher-level provider.

A nurse is caring for a client who received benzocaine spray prior to a recent bronchoscopy. The client presents with continuous cyanosis even with oxygen therapy. Which action should the nurse take next?

Notify the Rapid Response Team. Cyanosis unresponsive to oxygen therapy is a manifestation of methemoglobinemia, which is an adverse effect of benzocaine spray. Death can occur if the level of methemoglobin rises and cyanosis occurs. The nurse should notify the Rapid Response Team to provide advanced nursing care.

A nurse assesses a client's respiratory status. Which information is of highest priority for the nurse to obtain?

Occupation and hobbies Many respiratory problems occur as a result of chronic exposure to inhalation irritants used in a client's occupation and hobbies.

Four clients arrive in the emergency department simultaneously with chest pain. The client with which type of chest pain requires immediate attention by the nurse?

Pain radiating to the shoulder Chest pain radiating to the shoulder should be assumed to be cardiac in origin until proven otherwise; this requires the immediate attention of the nurse.

A client comes to the emergency department with a productive cough. Which symptom does the nurse look for that will require immediate attention?

Pink, frothy sputum Pink, frothy sputum is common with pulmonary edema and requires immediate attention and intervention to prevent the client's condition from getting worse. Blood in the sputum may occur with chronic bronchitis or lung cancer; because this condition is chronic, the situation does not require immediate attention.

The RN and the LPN/LVN are working together to provide care for a client hospitalized with dyspnea who requires all of these nursing actions. Which action is best accomplished by the RN?

Plan client and family teaching regarding upcoming pulmonary function testing. Developing the teaching plan is the most complex of the skills listed and requires RN education and licensure. Medication administration and monitoring of vital signs and client status after procedures can be accomplished by the LPN/LVN.

A client had a thoracentesis 1 day ago. He calls the home health agency and tells the nurse that he is very short of breath and anxious. What is the major concern of the nurse?

Pneumothorax A pneumothorax would be the complication of thoracentesis that causes the greatest concern, along with these symptoms. Although it is possible that an abscess has formed, this is not the most likely diagnosis because it would not cause a great deal of shortness of breath. It is not likely that pneumonia would develop this rapidly, causing this level of symptoms. Thoracentesis is not a cause of pulmonary emboli.

What is the effect of age-related decreased skeletal muscle strength on the effectiveness of gas exchange?

Reduced gas exchange as a result of decreased changes in pressures of the chest cavity. Rationale: Breathing occurs through changes in the size of and pressure within the chest cavity. Contraction and relaxation of chest muscles (and the diaphragm) cause changes in the size and pressure of the chest cavity. When skeletal muscle strength is decreased in these muscles, pressure changes are decreased, and less air moves in and out of the lungs. This reduced airflow limits gas exchange at the alveolar-capillary membrane.

A nurse assesses a client after a thoracentesis. Which assessment finding warrants immediate action?

The trachea is deviated toward the opposite side of the neck. A deviated trachea is a manifestation of a tension pneumothorax, which is a medical emergency.

What is the function of the turbinates?

They increase the surface area of the nose for heating and filtering. The turbinates increase the surface area of the nose, so that more heating, filtering, and humidifying of inspired air can occur before air passes into the nasopharynx.

A client has a fever of 104° F (40° C). In which direction, if any, does this shift the oxygen-hemoglobin dissociation curve?

To the right A client with fever has a higher demand for oxygen, so the curve will shift to the right for easier dissociation. The curve does not move up or down on the vertical axis. Moving to the left would cause hemoglobin to dissociate oxygen less easily.

A nurse is caring for a client who is scheduled to undergo a thoracentesis. Which intervention should the nurse complete prior to the procedure?

Validate that informed consent has been given by the client. A thoracentesis is an invasive procedure with many potentially serious complications. Verifying that the client understands complications and explaining the procedure to be performed will be done by the physician or nurse practitioner, not the nurse.

A nurse assesses a client who is prescribed varenicline (Chantix) for smoking cessation. Which manifestations should the nurse identify as adverse effects of this medication? (Select all that apply.)

Visual hallucinations Impaired judgment Varenicline (Chantix) has a black box warning stating that the drug can cause manic behavior and hallucinations. The nurse should assess for changes in behavior and thought processes, including impaired judgment and visual hallucinations.

A nurse is providing care after auscultating clients' breath sounds. Which assessment finding is correctly matched to the nurse's primary intervention?

Wheezes are heard in central areas. - The nurse administers an inhaled bronchodilator. Wheezes are indicative of narrowed airways, and bronchodilators help to open the air passages.