HA- Chapter 13: Prep U (Respiratory)

A client experiences increasing difficulty taking in a deep breath. For which health problem should the nurse focus when assessing this client? Anxiety Pulmonary embolism Congestive heart failure Chronic obstructive lung disease

orrect response: Chronic obstructive lung disease Explanation: The client with COPD may describe the dyspnea as not being able to "breathe or take a deep breath." Although dyspnea is associated with anxiety, pulmonary embolism, and congestive heart failure, the shortness of breath is not described as the inability to take in a deep breath.

During the lung assessment for a client with pneumonia, the nurse auscultates low-pitched bubbling, moist sounds that persists from early inspiration to early expiration. How should the nurse document these sounds? Coarse crackles Pleural friction rubs Sonorous wheezes Sibilant wheezes

orrect response: Coarse crackles Explanation: Low-pitched bubbling, moist sounds that persists from early inspiration to early expiration and sounds like softly separating Velcro should be documented as coarse crackles. These sounds are produced when inhaled air comes into contact with secretions in the large bronchi and trachea. Pleural friction rub is low-pitched, dry, grating sound which is superficial and occurs during both inspiration and expiration. Sonorous wheezes are low pitched snoring or moaning sounds that may be heard primarily during expiration but may be heard throughout the respiratory cycle. Sibilant wheezes are high-pitched musical sounds heard primarily during expiration but may also be heard on inspiration.

What color of sputum would support the diagnosis of heart failure? White Yellow Pink Rust

orrect response: Pink Explanation: Pink sputum is associated with heart failure. White sputum typically is seen with the common cold. Yellow sputum suggests a bacterial infection. Rust-colored sputum is associated with tuberculosis or pneumococcal pneumonia.

Which finding during an assessment of a client should alert the nurse to the presence of a persistent atelectasis? The presence of crepitus on palpation A depressed sternum and cartilages Retraction of intercostal spaces Unequal expansion of the chest

Unequal expansion of the chest Explanation: Unequal expansion of the chest indicates atelectasis or lung collapse. The inhaled air is unable to inflate the diseased lung; therefore, there is an unequal expansion of the chest. Crepitus on palpation can be found in clients with an open thoracic injury or with a tracheostomy. Sunken sternum and adjacent cartilages are seen in funnel chest. Retraction of intercostal spaces occurs in labored breathing.

The nurse auscultates the base of the lungs to assess for what reason? It is where fluid occurs with with pulmonary edema. It best reflects the health of the lungs. It indicates early infection.

Auscultation of the bases is important because it is where fluid occurs with pulmonary edema and the location for fluid accumulation with a pleural effusion. It does not indicate infection or health of the lungs.

The nurse is assessing a client's respiratory rate and rhythm during the beginning of a shift. The client's rate is 29 breaths per minute. How should the nurse respond to this assessment finding? Ask the client if she has recently exerted herself. Report the finding to the client's primary care provider. Ask the client if she has smoked recently. Palpate the client's anterior and posterior thorax.

Correct response: Ask the client if she has recently exerted herself. Explanation: Respiratory rate is highly dependent on recent exertion and activity. This variable should be ruled out before making a referral. Palpation is unlikely to ascertain the cause of the increased respiratory rate. Smoking is a possible cause, but activity is more likely.

A nurse is interviewing a client who complains of dyspnea of sudden onset. Based on this finding, the nurse should suspect which of the following causes? Emphysema Lung cancer Sleep apnea Bacterial infection

Correct response: Bacterial infection Explanation: Gradual onset of dyspnea is usually indicative of lung changes such as emphysema, whereas sudden onset is associated with viral or bacterial infections. Lung cancer and sleep apnea are chronic conditions, which would be more likely to result in a gradual onset of dyspnea.

What replaces resonance when fluid or solid tissue replaces air-containing lung or occupies the pleural space? Hyperresonance Dullness Tympany Chief complaint

Correct response: Dullness Explanation: Dullness replaces resonance when fluid or solid tissue replaces air-containing lung or occupies the pleural space.

While examining a client, the nurse observes the client's chest to be barrel shaped. The nurse would interpret this as indicating which of the following? Pneumonia Pectus excavatum Funnel chest Emphysema

Correct response: Emphysema Explanation: A barrel chest is often seen in emphysema because of hyperinflation of the lungs. A change in chest shape would be rare with pneumonia. Pectus excavatum or funnel chest is a congenital malformation.

A client comes to the clinic and states, "I have a bad cold and am having trouble breathing." The nurse checks the client's breath sounds and hears bilateral fine crackles at the base. Of what is this finding indicative? Fluid in the alveoli Fluid in the bronchioles Fluid in the bronchus No fluid present

Correct response: Fluid in the alveoli Explanation: When fluid fills the alveoli, fine crackles may be audible on auscultation. Excessive fluid in the alveoli may lead to airway collapse and decreased breath sounds. Fine crackles are not indicative of fluid in the bronchioles or bronchus or the absence of fluid in the lungs.

A nurse asks a client to say "ninety-nine" as the nurse palpates the posterior thorax. The nurse is assessing which of the following? Fremitus Egophony Chest expansion Bronchophony

Correct response: Fremitus Explanation: Fremitus is assessed by asking a client to say "ninety-nine" as the nurse palpates the thorax. Bronchophony is assessed by asking the client to say "ninety-nine" as the nurse auscultates the chest wall. Chest expansion is assessed by measuring the distance the examiner's thumbs move when the client takes a deep breath. Egophony is assessed by having the client repeat the letter "e" as the nurse auscultates.

What would the nurse expect to hear when auscultating the lungs of a client diagnosed with pleuritis? Friction rub Decreased breath sounds Sibilant wheeze Stridor

Correct response: Friction rub Explanation: In pleuritis, inflamed pleural surfaces lose their normal lubrication and rub together during breathing. Reduced volume of pleural fluid increases the transmission of lung sounds and leads to a possible friction rub. Decreased breath sounds may indicate an obstruction due to little air moving in and out. Sibilant wheezes are often heard with bronchitis; stridor occurs with severe broncholaryngospasms, such as croup. Stridor is associated with a loud, high-pitched crowing that is characteristic of epiglottis or other conditions that partially obstruct the upper airway.

The nurse is reviewing the client's health history and notes he has pectus excavatum. The nurse would assess the client for what? Funnel chest Pigeon chest Intercostal bulging Pectoriloquy

Correct response: Funnel chest Explanation: Pectus excavatum or funnel chest occurs when the sternum and adjacent cartilages are significantly sunken inward or dented. Pigeon chest or pectus carinatum occurs when the sternum protrudes backward. Intercostal bulging is noted with trapped air. Whispering pectoriloquy is identfied when sounds are louder and clearer than the wispered sounds.

A nurse auscultates a client's lungs and hears fine crackles. What is an appropriate action by the nurse? Listen again with the bell of the stethoscope Instruct the client to cough forcefully Have the client breathe through the mouth Assess for the use of accessory muscles

Correct response: Instruct the client to cough forcefully Explanation: When auscultating crackles in the lung fields, the nurse should instruct the client to cough forcefully in an effort to open the airways. Then the nurse should auscultate again and note any changes. Lung sounds should be listened to with the diaphragm because they are high-pitched sounds. The bell is used for low-pitched sounds such as abnormal heart sounds. Breathing through the mouth lets the air in quicker but will not clear the airways. Use of accessory muscles is seen with respiratory distress.

Which subjective finding in a client with tuberculosis should a nurse recognize as an indication of the onset of pleurisy? Dyspnea that is exaggerated by activity Knife-like pain that worsens on inspiration Throbbing pain that worsens on exhalation Dyspnea that is exaggerated by lying down

Correct response: Knife-like pain that worsens on inspiration Explanation: Knife-like pain that worsens on inspiration is a characteristic finding that indicates pleurisy in the client. Pleurisy or a pleural rub is caused when the inflamed pleural surface comes in contact with each other on inspiration. Dyspnea is exaggerated by activity but is not a characteristic feature. Clients with pleurisy do not have throbbing pain. Dyspnea in pleurisy is not exaggerated by lying down.

Which of the following would be most important for the nurse to remember when auscultating the thorax? Listen at each site for at least one complete respiratory cycle Have the client breathe deeply through the mouth Be alert to the client's comfort and offer rest periods Auscultate the base at the level of the sixth rib

Correct response: Listen at each site for at least one complete respiratory cycle Explanation: Although having the client breathe deeply through the mouth and being alert to the client's comfort are important when auscultating the lungs, it would be most important to listen at each site for one complete respiratory cycle to obtain the most accurate information. The nurse would auscultate from the apices to the bases at T10 and laterally from the axilla down to the seventh or eighth rib

A nurse observes a client sitting in the tripod position. What is an appropriate action by the nurse in response to this observation? Auscultate for the presence of crackles Palpate for tactile fremitus Percuss to determine diaphragmatic excursion Observe for the use of accessory muscles

Correct response: Observe for the use of accessory muscles Explanation: The tripod position is often assumed by the client with chronic obstructive pulmonary disease (COPD) in order to help elevate the diaphragm during inspiration. This is often accompanied by the use of accessory muscles of the neck. Crackles are present in pneumonia or fluid in the lungs. Tactile fremitus helps to assess for the presence of a consolidation such as pleural effusion or pneumonia. Diaphragmatic excursion assesses the movement of the diaphragm.

A client reports sharp and stabbing chest pain that worsens with deep breathing and coughing. A cardiac cause to this pain is ruled out. The description of the pain is consistent with what respiratory condition? Pleurisy Pneumonia Asthma Rales

Correct response: Pleurisy Explanation: Pleurisy can follow inflammation of the parietal pleura. Patients usually describe such pain as sharp or stabbing, worsening with deep breathing or coughing. Pneumonia does not always cause pain on respiration nor does asthma. Rales are an adventitious breath sound, not a respiratory condition.

A client is brought to the emergency department by ambulance after being involved in a motor vehicle accident. The nurse finds that he has decreased breath sounds over the left lung fields. What might the nurse suspect is the cause? Pneumothorax Atelectasis Muscular weakness Asthma

Correct response: Pneumothorax Explanation: Breath sounds may be decreased when air flow is decreased (as in obstructive lung disease or muscular weakness) or when the transmission of sound is poor (as in pleural effusion, pneumothorax, or COPD).

A client is brought to the emergency department by ambulance after being involved in a motor vehicle accident. The nurse finds that he has decreased breath sounds over the left lung fields. What might the nurse suspect is the cause? Pneumothorax Atelectasis Muscular weakness Asthma

Correct response: Pneumothorax Explanation: Breath sounds may be decreased when air flow is decreased (as in obstructive lung disease or muscular weakness) or when the transmission of sound is poor (as in pleural effusion, pneumothorax, or COPD).

A nurse is assessing a client with acute asthma. Which adventitious breath sound should the nurse expect to hear in this client? Fine crackles occurring late in inspiration Course crackles occurring from early inspiration to early expiration Sibilant wheezes heard primarily during expiration but may also be heard on inspiration Sonorous wheezes heard primarily during expiration but may be heard throughout the respiratory cycle

Correct response: Sibilant wheezes heard primarily during expiration but may also be heard on inspiration Explanation: Sibilant wheezes are often heard in cases of acute asthma or chronic emphysema. Fine crackles occurring late in inspiration are associated with restrictive diseases such as pneumonia and congestive heart failure. Course crackles that persist from early inspiration to early expiration may indicate pneumonia, pulmonary edema, or pulmonary fibrosis. Sonorous wheezes are often heard in cases of bronchitis or single obstructions and snoring before an episode of sleep apnea.

The nurse is assessing the apices of the client's lungs. The nurse should locate them at which position? At the level of the diaphragm Near the level of the eighth rib Slightly above the clavicle At about the tenth rib

Correct response: Slightly above the clavicle Explanation: The apex of each lung extends slightly above the clavicle. The base is at the level of the diaphragm. Laterally, lung tissue reaches the level of the eighth rib and posteriorly, the base lies at about the tenth rib.

When assessing the breath sounds of a newly admitted patient, the nurse notes increased transmission of voice sounds over the right lung. What would this indicate to the nurse? The lung is full of fluid The lung has an embolus The lung is overinflated The lung has become airless

Correct response: The lung has become airless Explanation: Increased transmission of voice sounds suggests that air-filled lung has become airless.

Which characteristic associated with respiratory effort should be considered when planning care for a client diagnosed with a brainstem injury? There is loss of involuntary respiratory control. The client will respond negatively to increased stimuli. There is an increased level of carbon dioxide in the blood. The client's oxygen levels in the blood will be increased.

Correct response: There is loss of involuntary respiratory control. Explanation: The brainstem contains the medulla and the pons, which control involuntary respiratory effort. The negative response to stimuli is unrelated to the client's respiratory effort. The client's breathing patterns will change according to cellular demands. The levels of carbon dioxide and oxygen in the blood also will vary based on the client's respiratory efforts as well as interventions used to sustain these efforts.

While assessing an adult client, the nurse observes decreased chest expansion at the bases of the client's lungs. The nurse should refer the client to a physician for possible atelectasis. pneumonia. chest trauma. chronic obstructive pulmonary disease.

Correct response: chronic obstructive pulmonary disease. Explanation: In chronic obstructive pulmonary disease, air is trapped in the lungs during forced expiration.

The nurse auscultates very loud, high-pitched lung sounds that are equal in length over a client's anterior chest. Which area did the nurse most likely hear these sounds? trachea manubrium between the scapula bilateral lower lobes

Correct response: trachea Explanation: Tracheal sounds are very loud and harsh with inspiratory and expiratory sounds equal in length, over the trachea in the neck. Bronchial sounds are louder and higher in pitch and are heard over the manubrium. Bronchovesicular sounds are heard between the scapula. Vesicular sounds are heard over most of the lung fields.

A high-pitched crowing sound from the upper airway results from tracheal or laryngeal spasm and is called what? Stridor Crackles Wheezes Rales

Explanation: Stridor, a high-pitched crowing sound from the upper airway, results from tracheal or laryngeal spasm. In severe laryngospasm, the larynx may completely close off. This life-threatening emergency requires immediate medical assistance. Crackles, wheezes, and rales are adventitious breath sounds heard upon auscultation of the lungs.

The nurse demonstrates appropriate technique when using what part of the hand to assess for fremitus in a client? Dorsal hand surface Pads of fingers Palmar base Fist

The palmar base or ulnar surface of the hand is best for assessing tactile fremitus because the area is especially sensitive to vibratory sensation. The dorsal surface of the hand is used to assess temperature. The fist is used in blunt percussion. Finger pads are used for fine discrimination such as pulses, texture, and size.