PrepU Ch. 17: Assessment of Respiratory Function

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 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"

A client has recently been diagnosed with malignant lung cancer. The nurse is calculating the client's smoking history in pack-years. The client reports smoking two packs of cigarettes a day for the past 11 years. The nurse correctly documents the client's pack-years as

22

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

463 and humidify inspired air

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%

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

A client experiencing hypothermia

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

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

Which is a true statement regarding air pressure variances?

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

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 nurse's hands move down the client's thorax

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 notes that a client has several normal breaths that are followed by apnea that varies in length. The nurse knows that this breathing pattern is also known as?

Biot respirations

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

Bradypnea

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

Clubbing of the fingers

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

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.

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

High or increased compliance occurs in which disease process?

Emphysema

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

The nurse is caring for a critically ill client in the ICU. The nurse documents the client's respiratory rate as bradypnea. The nurse recognizes that bradypnea is associated with which condition?

Increased intracranial pressure

What would the instructor tell the students purulent fluid indicates?

Infection

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

Kussmaul respirations

A client presents to the ED reporting severe coughing episodes. The client states that "the episodes are more intense at night." The nurse should suspect which of the following conditions based on the client's primary report?

Left-sided 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.

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.

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

No tenderness during palpation

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.)

Occupational and environmental influences Previous history of lung disease in the patient or family Previous history of smoking

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

Which diagnostic imaging modality is more accurate than computed tomography in detecting malignancies?

PET

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

Pleurisy

What is the primary function of the larynx?

Producing sound

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 the nurse perform first?

Pulse oximetry

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?

Ronchi

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

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

Swallow reflex

A client arrives at the physician's office stating 2 days of febrile illness, dyspnea, and cough. Upon assisting the client into a gown, the nurse notes that the client's sternum is depressed, especially on inspiration. Crackles are noted in the bases of the lung fields. Based on inspection, which will the nurse document?

The client has a funnel chest.

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

An client is described as having pectus carinatum. What would be the physical manifestation of this condition?

The sternum protrudes and the ribs are sloped backward.

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.

Which term refers to the volume of air inhaled or exhaled during each respiratory cycle?

Tidal volume

A nurse is caring for a client who has frequent upper respiratory infections. Which structure is most helpful in protecting against infection?

Tonsils

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

Type II

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 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.

Use of accessory muscles to breathe Purulent sputum with frequent coughing

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.

What is the difference between respiration and ventilation?

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

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.

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.

Pink, frothy sputum may be an indication of

pulmonary edema