PREPU RESP

A nonverbal client has just finished undergoing a bronchoscopy procedure and writes that he want to eat lunch now. Which intervention is necessary for the nurse to complete at this time? a) Assess for bowel sounds. b) Assess for a cough reflex. c) Call dietary services to send the client's tray now. d) Perform mouth care.

Assess for a cough reflex. Correct Before a bronchoscopy procedure, the nurse will administer preoperative medications, usually atropine and a sedative. These are prescribed to inhibit vagal stimulation, suppress the cough reflex, sedate the client, and relieve anxiety. After the procedure, it is important that the client take nothing by moth until the cough reflex returns. This is because the preoperative medication impairs the protective laryngeal reflex and swallowing for several hours. Once the client demonstrates a cough reflex or the nurse positively assesses one, then the nurse may offer ice chips and fluids.

If concern exists about fluid accumulation in a client's lungs, what area of the lungs will the nurse focus on during assessment? a) Posterior bronchioles b) Anterior bronchioles c) Bilateral lower lobes d) Left lower lobe

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 client appears to be breathing faster than during the last assessment. Which of the following interventions should the nurse perform? a) Assess the radial pulse. b) Inquire if there have been any stressful visitors. c) Count the rate of respirations. d) Assist the client to lie down.

Count the rate of respirations. Observing the rate and depth of respiration is an important aspect of a nursing assessment. The normal adult resting respiratory rate is 12 to 18 breaths per minute. Tachypnea is rapid breathing with a rate greater than 24 breaths per minute. An increase in the rate of respirations needs further investigation and must be reported

The nurse is assessing the lungs of a patient diagnosed with pulmonary edema. Which of the following would be expected upon auscultation? a) Absent breath sounds b) Egophony c) Crackles at lung bases d) Bronchial breath sounds

Crackles at lung bases A patient with pulmonary edema would be expected to have crackles in the lung bases, and possible wheezes. Egophony may occur in patients diagnosed with pleural effusion. Absent breath sounds occurs in pneumothorax. Bronchial breath sounds occur in consolidation, such as pneumonia.

Which of the following is a late sign of hypoxia? a) Cyanosis b) Restlessness c) Hypotension d) Somnolence

Cyanosis Cyanosis is a late sign of hypoxia. Hypoxia may cause restlessness and an initial rise in blood pressure that is followed by hypotension and somnolence.

You are working on a gerontology unit. You admit a 77-year-old with respiratory problems. You know that the amount of respiratory dead space increases with age. What do these changes result in? a) Increased diffusion of gases b) Decreased diffusion capacity for oxygen c) Decreased shunting of blood d) Increased ventilation

Decreased diffusion capacity for oxygen The amount of respiratory dead space increases with age. These changes result in a decreased diffusion capacity for oxygen with increasing age, producing lower oxygen levels in the arterial circulation. Therefore, options A, C, and D are incorrect.

You are caring for a patient with a lower respiratory tract infection. You know that this type of infection causes what? a) Impaired gas exchange b) Ruptured blebs in the lungs c) Collapsed bronchial structures d) Closed bronchial tree

Impaired gas exchange The lower respiratory tract consists of the lungs, which contain the bronchial and alveolar structures needed for gas exchange. A lower respiratory tract infection does not collapse bronchial structures or close the bronchial tree. An infection does not cause the blebs in the lungs to rupture.

You are a nurse in the radiology unit of your hospital. You are caring for a client who is scheduled for a lung scan. You know that lung scans need the use of radioisotopes and a scanning machine. Before the perfusion scan, what must the client be assessed for? a) Iodine allergy b) Bleeding c) Dysrhythmias d) Inflammation

Iodine allergy During lung scans, a radioactive contrast medium is administered intravenously for the perfusion scan. Before the perfusion scan, nurses must assess the client to check for allergies to iodine. Laryngoscopy determines inflammation. Dysrhythmias and bleeding are possible complications of mediastinoscopy.

The term for the volume of air inhaled and exhaled with each breath is a) tidal volume. b) expiratory reserve volume. c) vital capacity. d) residual volume.

tidal volume. Tidal volume is the volume of air inhaled and exhaled with each breath. Residual volume is the volume of air remaining in the lungs after a maximum expiration. Vital capacity is the maximum volume of air exhaled from the point of maximum inspiration. Expiratory reserve volume is the maximum volume of air that can be exhaled after a normal inhalation.

A nurse enters a client's room and observes a container with sputum. Upon questioning about the specimen, which of the following items of information from the client would necessitate the nurse to obtain a new specimen? a) "The specimen is from a deep cough." b) "The container used is sterile." c) "The lid is secured with tape." d) "I coughed that up about 8 hours ago."

"I coughed that up about 8 hours ago." A sputum specimen is obtained for analysis to identify pathogenic organisms. Expectoration is the usual method for collecting a sputum specimen. After a few deep breaths, the client coughs, using the diaphragm, and expectorates into a sterile container. The specimen is delivered to the laboratory within 2 hours. Allowing the specimen to stand for several hours in a warm room results in overgrowth of organisms and may make it difficult to identify the organisms.

The nurse working in the radiology clinic is assisting with a pulmonary angiography. The nurse knows that when monitoring clients after a pulmonary angiography, what should the physician be notified about? a) Excessive capillary refill b) Flushed feeling in the client c) Raised temperature in the affected limb d) Absent distal pulses

Absent distal pulses When monitoring clients after a pulmonary angiography, nurses must notify the physician about diminished or absent distal pulses, cool skin temperature in the affected limb, and poor capillary refill. When the contrast medium is infused, the client will sense a warm, flushed feeling.

Your client is scheduled for a bronchoscopy to visualize the larynx, trachea, and bronchi. What precautions would you recommend to the client before the procedure? a) Abstain from food for at least 6 hours before the procedure. b) Avoid sedatives or narcotics as they depress the vagus nerve. c) Avoid atropines as they dry the secretions. d) Practice holding the breath for short periods.

Abstain from food for at least 6 hours before the procedure. For at least 6 hours before bronchoscopy, the client must abstain from food or drink to decrease the risk of aspiration. Risk is increased because the client receives local anesthesia, which suppresses the reflexes to swallow, cough, and gag. The client receives medications before the procedure. Typically, atropine is given to dry secretions and a sedative or narcotic is given to depress the vagus nerve. The client may need to hold his or her breath for short periods during lung scans and for bronchoscopy.

Your patient has been diagnosed with heart failure. What breath sound should be assessed by the nurse? a) Expiratory wheezes b) Inspiratory wheezes c) Rhonchi d) Crackles

Crackles Crackles reflect underlying inflammation or congestion and are often present in such conditions as pneumonia, bronchitis, and congestive heart failure. Therefore options A, B, and C are incorrect.

While conducting the physical examination during assessment of the respiratory system, which of the following does a nurse assess by inspecting and palpating the trachea? a) Color of the mucous membranes b) Evidence of muscle weakness c) Evidence of exudate d) Deviation from the midline

Deviation from the midline During the physical examination, the nurse must inspect and gently palpate the trachea to assess for placement and deviation from the midline. The nurse examines the posterior pharynx and tonsils with a tongue blade and light and notes any evidence of swelling, inflammation, or exudate, as well as changes in color of the mucous membranes. The nurse also examines the anterior, posterior, and lateral chest walls for any evidence of muscle weakness

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? a) Placement of the probe on an earlobe b) Diagnosis of peripheral vascular disease c) Reduced lighting in the room d) Increased temperature of the room

Diagnosis of peripheral vascular disease Pulse oximetry is a noninvasive method of monitoring oxygen saturation of hemoglobin. A probe is placed on the fingertip, forehead, earlobe, or bridge of nose. Inaccuracy of results may be from anemia, bright lights, shivering, nail polish, or peripheral vascular disease.

"Swallowing down the wrong pipe" has happened to all of us. After a significant coughing spasm and gasping for air, we typically recover. Which upper airway structure malfunctions to cause the event? a) Nasopharynx b) Tonsils c) Epiglottis d) Oropharynx

Epiglottis The muscular nature of the pharynx allows for closure of the epiglottis during swallowing and relaxation of the epiglottis during respiration.

A nurse admits a patient to her unit with a presumptive diagnosis of pneumonia. When a sputum specimen is obtained, the nurse notes that the sputum is greenish and copious. The nurse notifies the patient's physician because these symptoms are indicative of what? a) Lung cancer b) Lung tumors c) Infection d) Pulmonary edema

Infection The nature of the sputum is often indicative of its cause. A profuse amount of purulent sputum (thick and yellow, green, or rust-colored) or a change in color of the sputum is a common sign of a bacterial infection. Options A, B, and D are not indicated by copious, green sputum.

A client has just undergone bronchoscopy. Which nursing assessment is most important at this time? a) Intellectual ability b) Memory c) Personality changes d) Level of consciousness (LOC)

Level of consciousness (LOC) Following bronchoscopy, LOC is the most important assessment because changes in the client's LOC may alert the nurse to serious neurologic problems. Memory, personality changes, and intellectual ability are important but don't take precedence at this time

Which of the following terms is used to describe the inability to breathe easily except in an upright position? a) Hypoxemia b) Dyspnea c) Orthopnea d) Hemoptysis

Orthopnea Patients with orthopnea are placed in a high Fowler's position to facilitate breathing. Dyspnea refers to labored breathing or shortness of breath. Hemoptysis refers to expectoration of blood from the respiratory tract. Hypoxemia refers to low oxygen levels in the blood.

You are caring for a patient who has returned to the unit following a bronchoscopy. The patient is asking for something to drink. Which criterion will determine when you will allow the patient to drink fluids? a) Absence of nausea b) Presence of a cough and gag reflex c) Ability to speak d) Ability to demonstrate deep inspiration

Presence of a cough and gag reflex After the procedure, it is important that the patient takes nothing by mouth until the cough reflex returns because the preoperative sedation and local anesthesia impair the protective laryngeal reflex and swallowing for several hours.

A 53-year-old client is seeing the physician today because he has had laryngitis for 2 weeks. After a thorough examination, the doctor orders medications and instructs the client to follow up in 1 week if his voice has not improved. What is the primary function of the larynx? a) Producing sound b) Protecting the lower airway from foreign objects c) Preventing infection d) Facilitating coughing

Producing sound The larynx, or voice box, is a cartilaginous framework between the pharynx and trachea. Its primary function is to produce sound.

Which of the following is a noninvasive method of continuously monitoring the oxygen saturation of hemoglobin (SaO2)? a) Sputum studies b) Pulmonary function testing c) Arterial blood gas analysis d) Pulse oximetry

Pulse oximetry Pulse oximetry is a noninvasive method of continuously monitoring SaO2. Measurements of blood pH of arterial oxygen and carbon dioxide tensions are obtained when managing patients with respiratory problems and adjusting oxygen therapy as needed. This is an invasive procedure. Pulmonary function testing assesses respiratory function and determines the extent of dysfunction. Sputum studies are done to identify if any pathogenic organisms or malignant cells are in the sputum

Your client has just had an invasive procedure to assess the respiratory system. What do you know should be assessed on this client? a) Masses in pleural space b) Watery sputum c) Respiratory distress d) Loss of consciousness

Respiratory distress After invasive procedures, the nurse must carefully check for signs of respiratory distress and blood-streaked sputum. Masses in the pleural space are a condition that affects fremitus. General examination of overall health and condition includes assessing the consciousness of a client.

A nurse is caring for a client after a lung biopsy. Which assessment finding requires immediate intervention? a) Client stating pain level of 7 out of 10 that decreases with pain medication b) Oxygen saturation level of 96% on 3 L of oxygen c) Client dozing when left alone but awakening easily d) Respiratory rate of 44 breaths/minute

Respiratory rate of 44 breaths/minute A respiratory rate of 44 breaths/minute is significant and requires immediate intervention. The client may be experiencing postoperative complications, such as pneumothorax or bleeding. An oxygen saturation level of 96% on 3 L of oxygen, a pain level of 7 out of 10 that decreases with pain medication, and dozing when left alone are normal and don't require further intervention

A patient is having her tonsils removed. The patient asks the nurse what function the tonsils serve. Which of the following would be the most accurate response? a) "The tonsils regulate the airflow to the bronchi." b) "The tonsils contain nerves that provoke sneezing." c) "The tonsils aid digestion." d) "The tonsils help to guard the body from invasion of organisms."

The tonsils help to guard the body from invasion of organisms." The tonsils, the adenoids, and other lymphoid tissue encircle the throat. These structures are important links in the chain of lymph nodes guarding the body from invasion of organisms entering the nose and throat. The tonsils do not aid digestion, do not contain nerves that provoke sneezing, nor do they regulate airflow to the bronchi.

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

Use of accessory muscles The use of accessory muscles for respiration indicates the client is having difficulty breathing. Diaphragmatic and pursed-lip breathing are two controlled breathing techniques that help the client conserve energy.

While auscultating the lungs of a client with asthma, the nurse hears a continuous, high-pitched whistling sound on expiration. The nurse will document this sound as which of the following? a) Pleural friction rub b) Crackles c) Wheezes d) Rhonchi

Wheezes Wheezes, usually heard on expiration, are continuous, musical, high pitched, and whistle-like sounds caused by air passing through narrowed airways. Often, wheezes are associated with asthma.

Which assessment finding would be most consistent with advanced emphysema? a) Dependent edema b) Aortic bruit c) Barrel-shaped chest d) Epigastric pain =

You selected: Barrel-shaped chest Barrel chest occurs as result of overinflation of the lungs. In a client with emphysema, the ribs are more widely spaced and the intercostal spaces tend to bulge on expiration. The apprearance of a such a client with advanced emphysema is easily detected.

A nurse is preparing a client with a pleural effusion for a thoracentesis. The nurse should: a) assist the client to a sitting position on the edge of the bed, leaning over the bedside table. b) place the client supine in the bed, which is flat. c) raise the arm on the side of the client's body on which the physician will perform the thoracentesis. d) raise the head of the bed to a high Fowler's position.

assist the client to a sitting position on the edge of the bed, leaning over the bedside table. A physician usually performs a thoracentesis when the client is sitting in a chair or on the edge of the bed, with the legs supported and the arms folded and resting on a pillow or on the bedside table. Raising an arm, lying supine, or raising the head of the bed won't allow the physician to easily access the thoracic cavity.

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 a) sibilant wheezes. b) sonorous wheezes. c) pleural friction rub. d) crackles.

pleural friction rub. A pleural friction rub is heard secondary to inflammation and loss of lubricating pleural fluid. Crackles are soft, high-pitched, discontinuous popping sounds that occur during inspiration. Sonorous wheezes are deep, low-pitched rumbling sounds heard primarily during expiration. Sibilant wheezes are continuous, musical, high-pitched, whistlelike sounds heard during inspiration and expiration.