Respiratory Mastery Quiz

Which actions would the nurse take to obtain subjective data about a client's respiratory status? *SATA* 1. Palpate the chest and back for masses. 2. Question the client about shortness of breath. 3. Check the hematocrit and hemoglobin values. 4. Inspect the skin and nails for integrity and color. 5. Ask the client about color and quantity of sputum.

2. Question the client about shortness of breath. 5. Ask the client about color and quantity of sputum.

Which action would the nurse take to prevent complications when caring for a client with a chest tube to water seal drainage system for a pneumothorax? *SATA* 1. Emptying the drainage system when full 2. Keeping the drainage system at heart level 3. Notifying the health care provider of drainage greater than 50 mL/h 4. Marking the time on the drainage unit every shift 5. Laying the drainage system on its side during transport

4. Marking the time on the drainage unit every shift

Which statement describes a client's tidal volume? A. Tidal volume is the volume of air inhaled and exhaled with each breath. B. Tidal volume is the amount of air remaining in the lungs after forced expiration. C. Tidal volume is the additional air forcefully inhaled after normal inhalation. D. Tidal volume is the additional air forcefully exhaled after normal exhalation.

A. Tidal volume is the volume of air inhaled and exhaled with each breath.

A client is extubated in the postanesthesia care unit after surgery. For which common response would the nurse be alert when monitoring the client for acute respiratory distress? A. Bradycardia B. Restlessness C. Constricted pupils D. Clubbing of the fingers

B. Restlessness Inadequate oxygenation of the brain from acute respiratory distress may produce restlessness or behavioral changes. The pulse increases with cerebral hypoxia from acute respiratory distress. The pupils dilate with cerebral hypoxia. Clubbing of the fingers is the result of prolonged hypoxia.

Which parameter describes the maximum volume of air a client's lungs may contain? A. Vital capacity B. Total lung capacity C. Inspiratory capacity D. Functional residual capacity

B. Total lung capacity Total lung capacity is the maximum volume of air that the lungs can contain. Vital capacity is the maximum volume of air that can be exhaled after maximum inspiration. Inspiratory capacity is the maximum volume of air that can be inhaled after maximum expiration. Functional residual capacity is the volume of air remaining in the lungs at the end of normal exhalation.

A client presents with hemoptysis. The nurse recalls that the clinical manifestation is associated with which disease? A. Anemia B. Pneumonia C. Tuberculosis D. Leukocytosis

C. Tuberculosis Hemoptysis is expectoration of blood-stained sputum derived from the lungs, bronchi, or trachea; this is a clinical manifestation of tissue erosion caused by tuberculosis. Anemia does not cause bleeding, but it may be caused by bleeding. Pneumonia causes sputum as a result of inflammation, but the sputum usually is yellow, not bloody. Leukocytosis is increased white blood cells; it does not cause hemoptysis.

When auscultating a client's chest, the nurse hears swishing sounds of normal breathing. How would the nurse document this finding? A. Adventitious sounds B. Fine crackling sounds C. Vesicular breath sounds D. Diminished breath sounds

C. Vesicular breath sounds Vesicular breath sounds are normal respiratory sounds heard on auscultation as inspired air enters and leaves the alveoli. "Adventitious" is the general term for all abnormal breath sounds. Crackles heard at the end of an inspiration are associated with fluid in the alveoli. Diminished breath sounds are evidence of a reduction in the amount of air entering the alveoli; this usually is caused by obstruction or consolidation.

Which amount is the normal value of a client's inspiratory reserve volume? A. 0.5 L B. 1.0 L C. 1.5 L D. 3.0 L

D. 3.0 L The normal value of inspiratory reserve volume is 3.0 L. The normal value of tidal volume is 0.5 L. The normal value of expiratory reserve volume is 1.0 L. The normal value of residual volume is 1.5 L.

The nurse described a client's abnormal breath sounds and included crackles, rhonchi, wheezes, and pleural friction rubs. Which breath sounds did the nurse hear? A. Vesicular B. Bronchial C. Adventitious D. Bronchovesicular

C. Adventitious Adventitious sounds are described as abnormal extra breath sounds to include crackles, rhonchi, wheezes, and pleural friction rubs. Vesicular sounds are relatively soft, low-pitched, gentle, rustling sounds. Bronchial sounds are louder and higher pitched and resemble air blowing through a hollow pipe. Bronchovesicular sounds have a medium pitch and intensity and are heard over the mainstem bronchi on either side of the sternum and posteriorly between the scapulae.

A client arrives in the emergency department with multiple crushing wounds of the chest, abdomen, and legs. What are the priority nursing assessments? A. Level of consciousness and pupil size B. Characteristics of pain and blood pressure C. Quality of respirations and presence of pulses D. Observation of abdominal contusions and other wounds

C. Quality of respirations and presence of pulses

The nurse provides education to a group of student nurses about pursed-lip breathing. The nurse would include which primary purpose of the respiratory exercise? A. Decreases chest pain B. Conserves energy C. Increases oxygen saturation D. Promotes elimination of CO2

D. Promotes elimination of CO2 Pursed-lip breathing increases positive pressure within the alveoli and makes it easier for clients to expel air from the lungs. This in turn promotes elimination of CO2. It also helps clients slow their breathing pattern and depth with respirations. It does not decrease chest pain, conserve energy, or increase oxygen saturation.

After percussing a client's posterior chest and hearing low-pitched hollow sounds over the whole chest, how will the nurse document the finding? A. Dull B. Flat C. Tympanic D. Resonance

D. Resonance Resonance is a low-pitched hollow sound normally heard over the air-filled lungs during percussion in healthy individuals. Dullness is a medium-pitched "thud-like" sound that might be heard with problems like lung consolidation due to pneumonia. Flatness is a high-pitched and short duration sound that might be heard over a pleural effusion. Tympanic sounds are high-pitched and musical; tympany might be heard over a pneumothorax.