PrepU: Ch. 20 Assessment of Respiratory Function

You are caring for a client admitted with chronic bronchitis. The client is having difficulty breathing, and the family asks you what causes this difficulty. What would be your best response?

"Conditions such as chronic bronchitis cause thickening of the bronchial mucosa so it makes it harder to breathe."

The nurse is calculating the patient's smoking history in pack-years. The patient has recently been diagnosed with malignant lung cancer. The patient states he has been smoking two packs of cigarettes a day for the past 11 years. The nurse correctly documents the patient's pack-years as which of the following?

22 Smoking history is usually expressed in pack-years, which is the number of packs of cigarettes smoked per day times the number of years the patient smoked. It is important to find out if the patient is still smoking or when the patient quit smoking. In this situation, the patient's pack years is 22 (2 × 11).

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 patient with recurrent hemoptysis who has undergone a bronchoscopy. Immediately following the procedure, the nurse should complete which of the following?

Assess the patient for a cough reflex.

Which assessment finding would be most consistent with advanced emphysema? Dependent edema Epigastric pain Barrel-shaped chest Aortic bruit

Barrel-shaped chest

If concern exists about fluid accumulation in a client's lungs, what area of the lungs will the nurse focus on during assessment?

Bilateral lower lobes Crackles are secondary to fluid in the alveoli and create a soft, discontinuous popping sound. Because fluid creates these adventitious sounds, the principle of gravity will remind the nurse to focus the assessment on the lower portion of the thorax or the lower lobes of the lungs.

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? Respiratory rate Cyanosis Son's statement Crackles

Cyanosis

The nurse is caring for a patient with extensive respiratory disease. Which of the following is a late sign of hypoxia in the patient?

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 6-month-old male client and his elder brother, a 3-year-old male, are being seen in the pediatric clinic for their third middle ear infection of the winter. The mother reports they develop an upper respiratory infection and 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.

Upon palpation of the sinus area, what would the nurse identify as a normal finding? Light not going through the sinus cavity Pain sensation behind the eyes Tenderness during palpation No sensation during palpation

No sensation during palpation

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.

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 The pons in the brainstem controls rate and depth of respirations. 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 client with a suspected pulmonary disorder undergoes pulmonary function tests. To interpret test results accurately, the nurse must be familiar with the terminology used to describe pulmonary functions. Which term refers to the volume of air inhaled or exhaled during each respiratory cycle? Functional residual capacity Tidal volume Maximal voluntary ventilation Vital capacity

Tidal volume Tidal volume refers to the volume of air inhaled or exhaled during each respiratory cycle when breathing normally. Normal tidal volume ranges from 400 to 700 ml. Vital capacity refers to the total volume of air that can be exhaled during a slow, maximal expiration after maximal inspiration. Functional residual capacity refers to the volume of air remaining in the lungs after a normal expiration. Maximal voluntary ventilation is the greatest volume of air expired in 1 minute with maximal voluntary effort.

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

Knowing respiratory physiology is important to understand how the disease process can work within that system. Which hollow tube transports air from the laryngeal pharynx to the bronchi?

Trachea

A nurse assesses a client's respiratory status. Which observation indicates that the client is having difficulty breathing? Diaphragmatic breathing Use of accessory muscles Pursed-lip breathing Controlled breathing

Use of accessory muscles

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, whistlelike 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.

A nurse practitioner diagnosed a patient with an infection in the maxillary sinuses. Select the area that the nurse palpated to make that diagnosis.

n the cheeks below the eyes