Med Surg Prep U Chapter 20

The nurse is caring for a client with an exacerbation of COPD and scheduled for pulmonary function studies using a spirometer. Which client statement would the nurse clarify?

"I will breathe in through my mouth and out through my nose."

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

tidal volume

What is the primary function of the larynx?

producing sound

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

A nurse understands that a safe but low level of oxygen saturation provides for adequate tissue saturation while allowing no reserve for situations that threaten ventilation. What is a safe but low oxygen saturation level for a patient?

95%

The nurse is caring for a client who is in respiratory distress. The physician orders arterial blood gases (ABGs) to determine various factors related to blood oxygenation. What site can ABGs be obtained from?

A puncture at the radial artery

Which is a true statement regarding air pressure variances?

Air is drawn through the trachea and bronchi into the alveoli during inspiration.

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 inhibitors ACE

A nurse enters a client's room and observes a container with sputum. Upon questioning about the specimen, which information from the client would necessitate the nurse to obtain a new specimen?

I coughed that up about 8 hours ago

The nurse is caring for a client with an exacerbation of COPD and scheduled for pulmonary function studies using a spirometer. Which client statement would the nurse clarify?

I will breathe in through my mouth and out through my nose

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

A client with chronic bronchitis is admitted with an exacerbation of symptoms. During the nursing assessment, the nurse will expect which of the following findings? Select all that apply

Purulent sputum with frequent coughing and Use of accessory muscles to breathe

A nurse would question the accuracy of a pulse oximetry evaluation in which of the following conditions?

a client experiencing hypothermia

A patient visited a health care clinic for treatment of upper respiratory tract congestion, fatigue, and sputum production that was rust-colored. Which of the following diagnoses is likely based on this history and inspection of the sputum?

an infection with pneumococcal pneumonia

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 nurses hands moved down the clients throax

The nurse is caring for a client with recurrent hemoptysis who has undergone a bronchoscopy. Immediately following the procedure, the nurse should complete which action?

assess the client for a cough reflex

A son brings his father into the clinic, stating that his father's color has changed to bluish around the mouth. The father is confused, with a respiratory rate of 28 breaths per minute and scattered crackles throughout. The son states this condition just occurred within the last hour. Which of the following factors indicates that the client's condition has lasted for more than 1 hour?

cyanosis

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

A client arrives at the physician's office stating dyspnea; a productive cough for thick, green sputum; respirations of 28 breaths/minute, and a temperature of 102.8° F. The nurse auscultates the lung fields, which reveal poor air exchange in the right middle lobe. The nurse suspects a right middle lobe pneumonia. To be consistent with this anticipated diagnosis, which sound, heard over the chest wall when percussing, is anticipated?

dull

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

frontal

A client is seen in the emergency room for a case of diabetic acidosis with the presence of Kussmaul respirations. What client condition is associated with the presence of Kussmaul respirations?

hyperventilation

Bradypnea is associated with which condition?

increased intracranial pressure

A client has been newly diagnosed with emphysema. The nurse should explain to the client that by definition, ventilation:

is breathing air in and out of the lungs.

The nurse answers a client's call light. The client reports an irritating tickling sensation in the throat, a salty taste, and a burning sensation in the chest. Upon further assessment, the nurse notes a tissue with bright red, frothy blood at the bedside. The nurse can assume the source of the blood is likely from the

lungs

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

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

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

orthopnea

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

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

pleurisy

Pink, frothy sputum may be an indication of

pulmonary edema

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

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

swallow reflex

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

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

tidal volume

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

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

warm and humidify inspired air

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.

In a patient diagnosed with increased intracranial pressure (IICP), the nurse would expect to observe which of the following respiratory rate or depth?

bradypnea

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

count the rate of respirations

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

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.

What is the difference between respiration and ventilation?

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

The nurse inspects the thorax of a patient with advanced emphysema. The nurse expects chest configuration changes consistent with a deformity known as:

barrel chest

A client presents to the emergency department with fluid overload. The nurse is concerned about fluid accumulation in the lungs. On which of the following areas would the nurse focus the lung assessment?

bilateral lower lobes

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

clubbing of the fingers

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 nurse is caring for a client who is in respiratory distress. The physician orders arterial blood gases (ABGs) to determine various factors related to blood oxygenation. What site can ABGs be obtained from?

a puncture at the radial artery