Respiratory Assessment

Which assessment finding would be most consistent with advanced emphysema?

Barrel-shaped chest

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

Clubbing of the fingers

Which is a late sign of hypoxia?

Cyanosis

High or increased compliance occurs in which disease process?

Emphysema

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.

Which of the following is a noninvasive method of continuously monitoring the oxygen saturation of hemoglobin (SaO2)?

Pulse oximetry

In which position should the client be placed for a thoracentesis?

Sitting on the edge of the bed

What is the difference between respiration and ventilation?

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

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.

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

tidal volume.

Which hollow tube transports air from the laryngeal pharynx to the bronchi?

trachea

The student nurse is caring for a client who has serial sputum tests ordered. The student asks the instructor why the sputum tests have to be repeated on successive days. What would be the instructor's best response?

"A negative sputum test does not always mean that there is no disease present, so more than one test may be needed."

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."

Following a chest X-ray, a patient has been diagnosed with a pleural effusion. The care team has concluded that the quantity of fluid in the patient's intrapleural space necessitates thoracentesis. What patient education should the nurse provide in anticipation of this procedure?

"It's very important that you remain still while the doctor is performing the procedure."

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 (ACE) inhibitors

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?

Assess for a cough reflex.

The nurse is assessing the lungs of a patient diagnosed with pulmonary edema. Which of the following would be expected upon auscultation?

Crackles at lung bases

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

The nurse working on a gerontology unit admits a 77-year-old with recent shortness of breath. The nurse knows that the amount of respiratory dead space increases with age. What do these changes result in?

Decreased diffusion capacity for oxygen

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 nurse is teaching a client about a loss of lung compliance and the effect with ventilation. What client condition is the nurse teaching the client about?

Emphysema

During a preadmission assessment, for what diagnosis would the nurse expect to find decreased tactile fremitus and hyperresonant percussion sounds?

Emphysema

High or increased compliance occurs in which condition?

Emphysema

While assessing for tactile fremitus, the nurse palpates almost no vibration. Which of the following conditions in this client's history will account for this finding?

Emphysema

A patient with sinus congestion points to a location on the inside of his eye as the area of pain. The nurse documents that the patient is complaining of pain in which sinus?

Ethmoid

A nurse is obtaining a health history from a client who reports hemoptysis for the past 2 months. The client reports occasional dyspnea. Which imaging study, ordered by the physician, will view the thoracic cavity while in motion?

Fluoroscopy

A patient is seen in the emergency room for a severe case of diabetic acidosis. The respiratory note indicates the presence of Kussmaul's respirations. The nurse knows that this diagnosis is associated with which of the following?

Hyperventilation

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

You are performing pulmonary function studies on clients in the clinic. What position do you know a client should be in to have maximum lung capacities and volumes?

In the standing position

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

No sensation during palpation

Which term will the nurse use to document the inability of a client to breathe easily unless positioned upright?

Orthopnea

A patient comes to the emergency department complaining of a knifelike pain when taking a deep breath. What does this type of pain likely indicate to the nurse?

Pleurisy

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

Pleurisy

The nurse is caring for a patient who has returned to the unit following a bronchoscopy. The patient is asking for something to drink. What criteria will determine when the nurse will allow the patient to drink fluids?

Presence of a cough and gag reflex

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.)

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

A patient exhibited signs of an altered ventilation-perfusion ratio. The nurse is aware that adequate ventilation but impaired perfusion exists when the patient has which of the following conditions?

Pulmonary embolism

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

The client is returning from the operating room following a bronchoscopy. Which action, performed by the nursing assistant, would the nurse stop if began prior to nursing assessment?

The nursing assistant is pouring a glass of water to wet the client's mouth.

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.

The nurse documents breath sounds that are soft, with inspiratory sounds longer than expiratory and found over the periphery of the lungs. Which of the following will the nurse chart?

Vesicular

The nurse is caring for a client with a decrease in airway diameter causing airway resistance. The client experiences coughing and mucus production. Upon lung assessment, which adventitious breath sounds are anticipated?

Wheezes

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

During assessment of the respiratory system, the nurse inspects and palpates the trachea in order to assess: trachea?

deviation from the midline.

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.

In relation to the structure of the larynx, the cricoid cartilage is

the only complete cartilaginous ring in the larynx.