302 Hinkle Chapter 20: Assessment of Respiratory Function PrepU

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 be assessed first?

pulse oximetry Pulse oximetry is a noninvasive method to determine arterial oxygen saturation. *Normal values are 95% and above*. Using this diagnostic test first provides rapid information of the client's respiratory system. All other options vary in amount of time and patient participation in determining further information regarding the respiratory system.

What is the difference between respiration and ventilation?

Ventilation is the movement of air in and out of the respiratory tract Ventilation is the actual movement of air in and out of the respiratory tract. Respiration is the exchange of oxygen and CO2 between atmospheric air and the blood and between the blood and the cells. Therefore, options A, C, and D are incorrect.

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

trachea The trachea is a hollow tube composed of smooth muscle and supported by C-shaped cartilage. The trachea transports air from the laryngeal pharynx to the bronchi and lungs. This is a cartilaginous framework between the pharynx and trachea that produces sound. The bronchioles are smaller subdivisions of bronchi within the lungs. The pharynx, or throat, carries air from the nose to the larynx and food from the mouth to the esophagus.

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 breathin in through my mouth and out through my nose" The nurse would clarify the client's statement of improper breathing technique. During a pulmonary function test using a spirometer, a nose clip prevents air from escaping through the client's nose when blowing into the spirometer. All other statements are correct.

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" During a pulmonary angiography, a contrast medium is injected into the femoral circulation. When the medium is infused, the client will feel warm and flushed, with a possibility of chest pain. The client will feel pressure when the catheter is inserted. The client does not typically feel light-headed or nauseated during this procedure.

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% With a normal value for the partial pressure of oxygen (PaO2) (80 to 100 mm Hg) and oxygen saturation (SaO2) (95% to 98%), there is a 15% margin of excess oxygen available to the tissues. With a normal hemoglobin level of 15 mg/dL and a PaO2 level of 40 mm Hg (SaO2 75%), there is adequate oxygen available for the tissues but no reserve for physiologic stresses that increase tissue oxygen demand.

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 When monitoring clients after a pulmonary angiography, nurses must notify the health care provider 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.

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 nurses hands move down the client's thorax While the nurse is assessing for tactile fremitus, the client is asked to repeat "ninety-nine" or "one, two, three," or "eee, eee, eee" as the nurse's hands move down the client's thorax. Vibrations are detected with the palmar surfaces of the fingers and hands, or the ulnar aspect of the extended hands, on the thorax. The hand(s) are moved in sequence down the thorax, and corresponding areas of the thorax are compared. Asking the client to say "one, two, three" while auscultating the lungs is not the proper technique to assess for tactile fremitus. The nurse assesses for anterior respiratory excursion by placing the thumbs along the costal margin of the chest wall and instructing the client to inhale deeply. The nurse assesses for diaphragmatic excursion by instructing the client to take a deep breath and hold it while the diaphragm is percussed.

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 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.

A client appears to be breathing faster than during the last assessment. Which of the following interventions should the nurse perform?

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.

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 Nurses must determine if the client has any allergies, particularly to iodine, shellfish, or contrast dye. During the procedure, the nurse should check for signs and symptoms of allergic reactions to the contrast medium, such as itching, hives, or difficulty in breathing. The nurses inspects for hematoma, absent distal pulses, after the procedure. When the contrast medium is infused, an urge to cough is often a sensation experienced by the client.

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 Tactile fremitus is assessed through vibrations of sound on the chest wall by palpation. Normally, fremitus is felt most over the large bronchi and least over the distant lung fields. Clients with emphysema exhibit almost no fremitus, because of the rupture of alveoli and the trapping of air. Air does not conduct sound well.

A client is being seen in the pediatric clinic for a middle ear infection. The client's mother reports that when the client develops an upper respiratory infection, 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.

The Family Nurse Practitioner is performing a physical examination of a client. The Nurse Practitioner examines the client's anterior, posterior, and lateral chest walls. What is the Nurse Practitioner assessing?

evidence of muscle weakness The nurse examines the anterior, posterior, and lateral chest walls to check for lesions, symmetry, deformities, skin color, and evidence of muscle weakness or weight loss. The nurse examines the posterior pharynx and tonsils with a tongue blade and light to detect any difficulty in swallowing or hoarseness. The nurse inspects and gently palpates the trachea to assess the placement and deviation from the midline.

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 Fluoroscopy enables the physician to view the thoracic cavity with all of its contents in motion. A fluoroscopy more precisely diagnoses the location of a tumor or lesion. An x-ray shows the size, shape, and position of the lungs. An MRI and CT produce axial views of the lungs.

A client with sinus congestion complains of discomfort when the nurse is palpating the supraorbital ridges. What sinus is the client referring?

frontal The nurse may palpate the frontal and maxillary sinuses for tenderness. Using the thumbs, the nurse applies gentle pressure in an upward fashion at the supraorbital ridges (frontal sinuses) and in the cheek area adjacent to the nose (maxillary sinuses). The ethmoidal sinuses are located between the nose and eyes. The sphenoidal sinuses are behind the nose between the eyes.

A client is seen in the emergency room for a case of diabetic acidosis with the presence of Kussmaul respirations. What client condition is associated with the presence of Kussmaul respirations?

hyperventilation Hyperventilation is an increased rate and depth of breathing that results in decreased PaCO2 levels and inspiration and expiration nearly equal in duration This is associated with exertion, anxiety, and metabolic acidosis. This hyperventilation is called Kussmaul respiration if associated with diabetic ketoacidosis or renal origin. Bradypnea is breaths slower than 10 per minute. Tachypnea is rapid, shallow breathing exceeding 24 breaths per minute. Hypoventilation is shallow, irregular breathing.

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 Airflow is decreased with atelectasis, which is a bronchial obstruction from collapsed lung tissue. If there is an obstruction, there is limited or no gas exchange in this area. Impaired gas exchange is thus the most likely nursing diagnosis with atelectasis.

A client arrived in the emergency department with a sharp object penetrating the diaphragm. When planning nursing care, which nursing diagnosis would the nurse identify as a priority?

impaired gas exchange The diaphragm separates the thoracic and abdominal cavities. On inspiration, the diaphragm contracts and moves downward, creating a partial vacuum. Without this vacuum, air is not as efficiently drawn into the thoracic cavity. Hypoxia or hypoxemia may occur from the poor availability of oxygen. Although the nursing diagnosis Acute Pain is probable, gas exchange is a higher priority. Ineffective Airway Clearance is the least concern because the problem is with ventilation.

Which respiratory volume is the maximum volume of air that can be inhaled after maximal expiration?

inspiratory reserve volume Inspiratory reserve volume is normally 3000 mL. Tidal volume is the volume of air inhaled and exhaled with each breath. Expiratory reserve volume is the maximum volume of air that can be exhaled forcibly after a normal exhalation. Residual volume is the volume of air remaining in the lungs after a maximum exhalation.

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 Ventilation is the actual movement of air in and out of the respiratory tract. Diffusion is the exchange of oxygen and CO2 through the alveolar-capillary membrane. Pulmonary perfusion refers to the provision of blood supply to the lungs. A mechanical ventilator assists patients who are unable to breathe on their own.

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 Assessment of lung sounds includes auscultation for airflow through the bronchial tree. The nurse evaluates for fluid or solid obstruction in the lung. When airflow is decreased, as with fluid or secretions, adventitious sounds may be auscultated. Often crackles are heard with fluid in the airways.

The nurse is performing an assessment for a patient with congestive heart failure. The nurse asks if the patient has difficulty breathing in any position other than upright. What is the nurse referring to?

orthopnea Orthopnea (inability to breathe easily except in an upright position) may be found in patients with heart disease and occasionally in patients with chronic obstructive pulmonary disease (COPD). Dyspnea (subjective feeling of difficult or labored breathing, breathlessness, shortness of breath) is a multidimensional symptom common to many pulmonary and cardiac disorders, particularly when there is decreased lung compliance or increased airway resistance. Tachypnea is abnormally rapid respirations. Bradypnea is abnormally slow respirations.

What is the primary function of the larynx?

producing sound The larynx, or voice box, is a cartilaginous framework between the pharynx and trachea. Its primary function is to produce sound. While the larynx assists in protecting the lower airway, this is mainly the function of the epiglottis. Facilitating coughing is a secondary function of the larynx. Preventing infection is the main function of the tonsils and adenoids.

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

swallow reflex The physician sprays a local anesthetic into the client's throat before performing a bronchoscopy. The nurse must assess the swallow reflex when the client returns to the unit and before giving him anything by mouth. The nurse should also assess for medication allergies, carotid pulse, and deep breathing, but they aren't the priority at this time.

The nurse receives an order to obtain a sputum sample from a client with hemoptysis. When advising the client of the physician's order, the client states not being able to produce sputum. Which suggestion, offered by the nurse, is helpful in producing the sputum sample?

take deep breaths and cough forcefully Taking deep breaths moves air around the sputum and coughing forcefully moves the sputum up the respiratory tract. Once in the pharynx, the sputum can be expectorated into a specimen container. Producing a gag reflex elicits stomach contents and not respiratory sputum. Dilute and thinned secretions are not helpful in aiding expectoration. A sputum culture is not a component of oral secretions.

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 question asks for a documentation based on inspection. A funnel chest, known as pectus excavatum, has the sternum depressed from the second intercostal space, and it is more pronounced on inspiration. The nurse would not diagnose chronic respiratory disease or pneumonia. The client would also not prescribe a cough suppressant.

Which homeostatic mechanism would the body of a critically ill client use to maintain normal pH?

the lungs eliminate carbonic acid by blowing off more CO2 To maintain normal pH in critically ill clients, the lungs eliminate carbonic acid by blowing off more CO2. To maintain normal pH in critically ill clients, the lungs conserve CO2 by slowing respiratory volume. The lungs would retain more CO2 during an acid-base imbalance in cases of metabolic alkalosis. The kidneys would retain more HCO3 to compensate during an acid-base imbalance in cases of metabolic acidosis.

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 into the clients mouth When completing a procedure which sends a scope down the throat, the gag reflex is anesthetized to reduce discomfort. Upon returning to the nursing unit, the gag reflex must be assessed before providing any food or fluids to the client. The client may need assistance following the procedure for activity and ambulation but this is not restricted in the post procedure period.

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

the only complete cartilaginous ring in the larynx The cricoid cartilage is located below the thyroid cartilage. The arytenoid cartilages are used with the thyroid cartilage in vocal cord movement. The thyroid cartilage is the largest of the cartilage structures and part of it forms the Adam's apple. The epiglottis is the valve flap of cartilage that covers the opening to the larynx during swallowing.

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 Sibilant or hissing or whistling wheezes are continuous musical sounds that can be heard during inspiration and expiration. They result from air passing through narrowed or partially obstructed air passages and are heard in clients with increased secretions. The crackling or grating sounds heard during inspiration or expiration are friction rubs. They occur when the pleural surfaces are inflamed.

The term for the volume of air inhaled and exhaled with each breath is

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.

Perfusion refers to blood supply to the lungs, through which the lungs receive nutrients and oxygen. What are the two methods of perfusion?

two methods of perfusion are the bronchial and pulmonary circulation The two methods of perfusion are the bronchial and pulmonary circulation. There is no alveolar circulation. Capillaries are the vessels that performs the perfusion regardless of which area of the lung they are in.

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 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*. In this situation, the client's pack-years is 22 (2 × 11). It is important to find out whether the client is still smoking or when the client quit smoking.

The nurse is reviewing the blood gas results for a patient with pneumonia. What arterial blood gas measurement best reflects the adequacy of alveolar ventilation?

PaCO2 When the minute ventilation falls, alveolar ventilation in the lungs also decreases, and the PaCO2 increases.

A nurse assesses a client with crackles. What medical condition should the nurse suspect? Select all that apply.

Asthma Chronic bronchitis A collapsed alveoli Pulmonary fibrosis Crackles are discrete, non-continuous sounds that result from the delayed reopening of collapsed alveoli. Crackles may or may not be cleared by coughing. They reflect underlying inflammation or congestion and are often present in such conditions as pneumonia, bronchitis, heart failure, asthma, bronchiectasis, and pulmonary fibrosis. Crackles are usually heard on inspiration, but they may also be heard on expiration. A client with a pneumothorax will have absent breath sounds.

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

Kussmaul respirations Kussmaul respirations are seen in patients with diabetic ketoacidosis. In Cheyne-Stokes respiration, rate and depth increase, then decrease until apnea occurs. Biot's respiration is characterized by periods of normal breathing (3 to 4 breaths) followed by a varying period of apnea (usually 10 to 60 seconds).

The nurse is caring for a client with hypoxemia of unknown cause. Which of the following oxygen transport considerations does the nurse identify as crucial to circulate oxygen in the body system? Select all that apply.

Oxygen is dissolved. Oxyhemoglobin circulates to the body tissue. Adequate red blood cells are needed for oxygen transport. Oxygen transport occurs by dissolving oxygen in the water in the plasma and combining oxygen with red blood cells (oxyhemoglobin). Normal red blood cell count is needed for oxygen transport. High blood pressure does not disrupt transport unless there is disruption in perfusion via a bleeding or occlusion. Dissolved oxygen is the only form which can diffuse across cell membranes.

A nurse is performing a physical assessment on a client who has a history of a respiratory infection. Which documentation, completed by the nurse, indicates the resolution of the infection? Select all that apply.

Lung fields documented as clear in the bases. Palpable vibrations over the chest wall when the client speaks. Decreased fremitus when the client speaks "99." Bronchovesicular sounds heard over the upper lung fields. To determine if the client's respiratory infection has resolved, the nurse should assess the client's normal respiratory status. Lungs will return to clear breath sounds. Palpable vibrations will be felt, as there is no blockage in the transmission. A client with consolidation of a lobe of the lung from pneumonia has increased tactile fremitus over that lobe. A decreased fremitus would indicate resolution of infection Bronchovesicular sounds will be noted over the upper lung fields. An increased fremitus is noted as the client speaks "99." Dull percussed sounds indicate an area of consolidation.

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 MRI uses magnetic fields and radiofrequency signals to produce a detailed diagnostic image. MRI can visualize soft tissues, characterize nodules, and help stage carcinomas. The other options describe different studies.

The nurse is studying for a physiology test over the respiratory system. What should the nurse know about central chemoreceptors in the medulla?

They respond to changes in *CO2 levels* and *hydrogen ion concentrations (pH)* in the cerebrospinal fluid. Central chemoreceptors in the medulla respond to changes in CO2 levels and hydrogen ion concentrations (pH) in the cerebrospinal fluid. Central chemoreceptors do not respond to changes in the O2 levels in the brain, changes in CO2 levels in the brain, changes in O2 levels, and bicarbonate levels in the cerebrospinal fluid.

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

a client experiencing hypothermia Pulse oximetry is a noninvasive method of continuously monitoring the oxygen saturation of hemoglobin. The reading is referred to as SpO2. A probe or sensor is attached to the fingertip, forehead, earlobe, or bridge of the nose. Values less than 85% indicate that the tissues are not receiving enough oxygen. *SpO2 values obtained by pulse oximetry are unreliable in states of low perfusion such as 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 ABGs determine the blood's pH, oxygen-carrying capacity, levels of oxygen, CO2, and bicarbonate ion. Blood gas samples are obtained through an arterial puncture at the radial, brachial, or femoral artery. A client also may have an indwelling arterial catheter from which arterial samples are obtained. Blood gas samples are not obtained from the pleural surfaces or trachea and bronchi.

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?

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.

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 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 presence of both inspiratory and expiratory wheezing usually signifies asthma if the individual does not have heart failure. Sudden dyspnea is an indicator of the other choices.

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.

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

clubbing of the fingers Clubbing of the fingers is a change in the normal nail bed. It appears as sponginess of the nail bed and loss of the nail bed angle. It is a sign of lung disease that is found in patients with chronic hypoxic conditions, chronic lung infections, or malignancies of the lung. The other signs listed may represent only a temporary hypoxia.

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 Cyanosis, a bluish coloring of the skin, is a very late indicator of hypoxia. The presence or absence of cyanosis is determined by the amount of unoxygenated hemoglobin in the blood. Cyanosis appears when there is at least 5 g/dL of unoxygenated hemoglobin.

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 client's appearance may give clues to respiratory status. Cyanosis, a bluish coloring of the skin, is a very late indicator of hypoxia. The presence of cyanosis is from decreased unoxygenated hemoglobin. In the presence of a pulmonary condition, cyanosis is assessed by observing the color of the tongue and lips.

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

emphysema Emphysema is associated with decreased tactile fremitus and hyperresonant percussion sounds. Bronchitis is associated with normal tactile fremitus and resonant percussion sounds. Atelectasis is associated with absent tactile fremitus and dull percussion sounds. Pulmonary edema is associated with normal tactile fremitus and resonant percussion sounds.

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 The ethmoidal sinuses are located between the eyes and behind the nose. Inflammation and swelling block drainage into the nose; eventually an infection results.

What happens to the diaphragm during inspiration?

it contracts and flattens During inspiration, the diaphragm contracts and flattens, which expands the thoracic cage and increases the thoracic cavity.

When assessing a client, which adaptation indicates the presence of respiratory distress?

orthopnea Orthopnea is the inability to breathe easily except when upright. This positioning can mean while in bed and propped with a pillow or sitting in a chair. If a client cannot breathe easily while lying down, there is an element of respiratory distress.

The nurse auscultated a patient's middle lobe of the lungs for abnormal breath sounds. To do this, the nurse placed the stethoscope on the:

the anterior surface of the right side of the chest, between the fourth and fifth rib The middle lobe of the lung is only found on the right side of the thorax and can only be assessed anteriorly. It is located at the fourth rib, at the right sternal border and extends to the fifth rib, in the midaxillary line.

There are three types of alveolar cells. Type I and type II cells make up the alveolar epithelium. Type I cells account for 95% of the alveolar surface area and serve as a barrier between the air and the alveolar surface; type II cells account for only 5% of this area but are responsible for producing type I cells and surfactant. Surfactant reduces surface tension, thereby improving overall lung function. Alveolar macrophages, the third type of alveolar cells, are phagocytic cells that ingest foreign matter and, as a result, provide an important defense mechanism. Type IV is not a category of alveolar cells.

type II There are three types of alveolar cells. Type I and type II cells make up the alveolar epithelium. Type I cells account for 95% of the alveolar surface area and serve as a barrier between the air and the alveolar surface; type II cells account for only 5% of this area but are responsible for producing type I cells and surfactant. Surfactant reduces surface tension, thereby improving overall lung function. Alveolar macrophages, the third type of alveolar cells, are phagocytic cells that ingest foreign matter and, as a result, provide an important defense mechanism. Type IV is not a category of alveolar cells.

A nurse assesses a client's respiratory status. Which observation indicates that the client is having difficulty 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.

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

warm and humidify inspired air The vascular and ciliated mucous lining of the nasal cavities warms and humidifies inspired air. It is the function of the cilia alone to move mucus in the nasal cavities and filter the inspired air.

Pink, frothy sputum may be an indication of

pulmonary edema Profuse frothy, pink material, often welling up into the throat, may indicate pulmonary edema. Foul-smelling sputum and bad breath may indicate a lung abscess, bronchiectasis, or an infection caused by fusospirochetal or other anaerobic organisms.

Which is a true statement regarding air pressure variances?

air is drawn through the trachea and bronchi into the alveoli during inspiration Air flows from a region of higher pressure to a region of lower pressure. During inspiration, movement of the diaphragm and other muscles of respiration enlarge the thoracic cavity, thereby lowering the pressure inside the thorax to a level below that of atmospheric pressure.

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 Common causes of cough include asthma, gastrointestinal reflux disease, infection, aspiration, and side effects of medications, such as angiotensin converting enzyme (ACE) inhibitors. The other medications listed are not associated with causing a cough.

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 cough reflex 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 mouth 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.

A client arrives in the emergency department reporting shortness of breath. She has 3+ pitting edema below the knees, a respiratory rate of 36 breaths per minute, and heaving respirations. The nurse auscultates the client's lungs to reveal coarse, moist, high-pitched, and non-continuous sounds that do not clear with coughing. The nurse will document these sounds as which type?

crackles Crackles are adventitious breath sounds that are high-pitched, discontinuous, and popping; they may or may not clear with coughing and are moist. Often crackles are associated with heart failure.

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

crackles at the 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.

The nurse is completing a physical assessment of a client's trachea. The nurse inspects and palpates the trachea for

deviation from midline During the physical examination, the nurse must inspect and gently palpate the trachea to assess for placement and deviation from the midline. The trachea is normally in the midline as it enters the thoracic inlet behind the sternum, but it may be deviated by a mass in the neck or mediastinum. Pulmonary disorders, such as a pneumothorax or pleural effusion, may also displace the trachea. 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.

While conducting the physical examination during assessment of the respiratory system, which conditions does the nurse assess by inspecting and palpating the trachea?

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.

High or increased compliance occurs in which disease process?

emphysema High or increased compliance occurs if the lungs have lost their elasticity and the thorax is overdistended, as in emphysema. Conditions associated with decreased compliance include pneumothorax, pleural effusion, and acute respiratory distress syndrome (ARDS).

Which of the following is an age-related change associated with the lung?

increased thickness of the alveolar membranes Age-related changes associated with the lung include increased thickness of the alveolar membranes, decreased elasticity of alveolar air sacs, increased diameter of alveoli ducts, and increased collagen of alveolar membranes.

During a pulmonary assessment, the nurse observes the chest for configuration. She identifies the findings as normal. Which of the following would be consistent with normal assessment?

lateral diameter is greater than the anteroposterior diameter Inspecting the thorax is part of assessment of the respiratory system. Normally, the ratio of the anteroposterior diameter to the lateral diameter is 1:2. Chest deformities are associated with respiratory disease.

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 *Blood from the lung is usually bright red, frothy, and mixed with sputum*. Initial symptoms include a tickling sensation in the throat, a salty taste, a burning or bubbling sensation in the chest, and perhaps chest pain, in which case the client tends to splint the bleeding side. This blood has an alkaline pH (>7.0). *Blood from the stomach is vomited rather than expectorated, may be mixed with food, and is usually much darker; it is often referred to as "coffee ground emesis."* This blood has an acidic pH (<<7.0). Bloody sputum from the nose or the nasopharynx is usually preceded by considerable sniffing, with blood possibly appearing in the nose.

The student nurse is learning breath sounds while listening to a client in the physician's office. An experienced nurse is assisting and notes air movement over the trachea to the upper lungs. The air movement is noted equally on inspiration as expiration. Which breath sounds would the nurse document?

normal bronchovesicular sounds Air movement over the trachea and upper lungs is a normal finding for bronchovesicular sounds. The air movement is noted equally on inspiration as expiration. The other choices do not match type of breath sound for the location in question.

A young adult visited a clinic because he was injured during a softball game. He told the nurse that the ball struck him in his "Adam's apple." To assess the initial impact of injury, the nurse:

palpates the thyroid cartilage The term "Adam's Apple" is used to refer to a lump or protrusion, a laryngeal prominence. It is formed by the angle of the thyroid cartilage surrounding the larynx.

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.

the diaphragm contracts and elongates the chest cavity The diaphragm contracts during inspiration and pulls the lungs in a downward and forward direction. The abdomen appears to enlarge because the abdominal contents are being compressed by the diaphragm. With inspiration, the diaphragmatic pull elongates the chest cavity, and the external intercostal muscles (located between and along the lower borders of the ribs) contract to raise the ribs, which expands the anteroposterior diameter. The effect of these movements is to decrease the intrapulmonary pressure.

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 The main function of the respiratory system is to exchange oxygen and CO2 between the atmospheric air and the blood and between the blood and the cells. This process is called respiration. The purpose of respiration is not to move any gas into the expired air; retained air is simply a distractor for this question; and atmospheric air is not exchanged between the blood and the cells.

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 When a blood clot exists in a pulmonary vessel (embolus), impaired perfusion results. However, ventilation is adequate. With the other choices, ventilation is impaired but perfusion is adequate.

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 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?

The nurse is caring for a client with recurrent hemoptysis who has undergone a bronchoscopy. Immediately following the procedure, the nurse should complete which action?

assess the client for a cough reflex After the procedure, the client must take nothing by mouth until the cough reflex returns, because the preoperative sedation and local anesthesia impair the protective laryngeal reflex and swallowing. Once the client demonstrates a cough reflex, the nurse may offer ice chips and eventually fluids. The client is sedated during the procedure, not afterward. The client is not required to maintain bed rest following the procedure.

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?

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.

During a preadmission assessment, the nurse finds increased tactile fremitus. She knows this sign is consistent with which of the following diagnoses?

pneumonia Air does not conduct sound well, but a solid substance such as a tumor, or fluid that increases the density of the lung, as occurs in pneumonia, does. Therefore, an increase in solid tissue of the normally air-filled lung enhances fremitus, and an increase in air in the lung impedes sound. A patient with consolidation of a lobe of the lung from pneumonia has increased tactile fremitus over that lobe.

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 dull percussed sound, heard over the chest wall, is indicative of little or no air movement in that area of the lung. Lung consolidation such as in pneumonia or fluid accumulation produces the dull sound. A tympanic sound is a high-pitched sound commonly heard over the stomach or bowel. A resonant sound is noted over normal lung tissue. A hyper resonant sound is an abnormal lower pitched sound that occurs when free air exists in disease processes such as pneumothorax.

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 intercranial pressure Bradypnea is associated with *increased intracranial pressure, brain injury, and drug overdose*. Respirations are slower than the normal rate (<10 breaths/min), with normal depth and regular rhythm. Tachypnea is commonly seen in clients with pneumonia, pulmonary edema, and metabolic acidosis.

What would the instructor tell the students purulent fluid indicates?

infection A small amount of fluid lies between the visceral and parietal pleurae. When excess fluid or air accumulates, the physician aspirates it from the pleural space by inserting a needle into the chest wall. This procedure, called thoracentesis, is performed with local anesthesia. Thoracentesis also may be used to obtain a sample of pleural fluid or a biopsy specimen from the pleural wall for diagnostic purposes such as a culture, sensitivity, or microscopic examination. Purulent fluid is the recommended diagnosis for infection. Serous fluid may be associated with cancer, inflammatory conditions, or heart failure.

A pediatrician diagnosed a child with swollen and inflamed adenoids. The nurse practitioner confirmed the diagnosis by:

inspecting the roof of the naspharynx The adenoids are clusters of lymph tissue located between the *back of the nose and the back of the throat in the nasopharynx*. The adenoids are usually inspected by using a special mirror. They cannot be seen by looking directly into the mouth.

The nurse is caring for a client who is scheduled for a bronchoscopy. The nurse understands that it is important to provide the required information and appropriate explanations for any diagnostic procedure to a client with a respiratory disorder in a way that

manages decreased energy levels In addition to the nursing management of individual tests, clients with respiratory disorders require informative and appropriate explanations of any diagnostic procedures they will experience. Nurses must remember that for many of these clients, breathing may in some way be compromised and energy levels may be decreased. For that reason, explanations should be brief, yet complete, and may need to be repeated later after a rest period. The nurse must also ensure adequate rest periods before and after the procedures. After invasive procedures, the nurse must carefully assess for signs of respiratory distress.

A black client with asthma seeks emergency care for acute respiratory distress. Because of this client's dark skin, the nurse should assess for cyanosis by inspecting the:

mucous membranes Skin color doesn't affect the mucous membranes. Therefore, the nurse can assess for cyanosis by inspecting the client's mucous membranes. The lips, nail beds, and earlobes are less-reliable indicators of cyanosis because they're affected by skin color.

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

no sensation during lung palpation Sinus assessment involves using the thumbs to apply gentle pressure in an upward fashion at the sinuses. Tenderness suggests inflammation. The sinuses can be inspected by transillumination, where a light is passed through the sinuses. If the light fails to penetrate, the cavity contains fluid.

The nurse auscultates the lung sounds of a client during a routine assessment. The sounds produced 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 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, whistle-like sounds heard during inspiration and expiration.

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 Pleuritic pain from irritation of the parietal pleura is sharp and seems to "catch" on inspiration; patients often describe it as being "like the stabbing of a knife." In carcinoma, the pain may be dull and persistent because the cancer has invaded the chest wall, mediastinum, or spine.

A student nurse is working with a client who is diagnosed with head trauma. The nurse has documented Cheyne-Stokes respirations. The student would expect to see which of the following?

regular breathing where the rate and depth increase, then decrease Observing the rate and depth of respiration is an important aspect of the nursing assessment. Certain patterns of breathing are characteristic of specific disease states or conditions. Head trauma can cause damage to the respiratory center in the brain, thereby altering the rate and depth of respirations. Cheyne-Stokes breathing is characterized by a regular cycle in which the rate and depth of breathing increase, then decrease until apnea occurs.

A client with chronic bronchitis is admitted to the health facility. Auscultation of the lungs reveals low-pitched, rumbling sounds. What breath sound should the nurse document?

rhonchi Rhonchi or sonorous wheezes are deep, low-pitched, rumbling sounds heard usually on expiration. The etiology of rhonchi is associated with chronic bronchitis. Rales or crackles are soft, high-pitched sounds. A venous hum is a blood flow humming sound. Bronchovesicular sound is an intermediate pitch with expiration and inspiration.

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

sitting at the edge of the bed If possible, place the client upright or sitting on the edge of the bed with the feet supported and arms and head on a padded over-the-bed table. Other positions in which the client could be placed include straddling a chair with the arms and head resting on the back of the chair, or lying on the unaffected side with the head of the bed elevated 30 to 45 degrees (if the client is unable to assume a sitting position).

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, whistle-like 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.

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 A decrease in airway diameter, such as in asthma, produces breath sounds of wheezes. Wheezes are a whistling type of sound relating to the narrowing on the airway. A wheeze can have a high-pitched or low-pitched quality. Crackles, also noted as rales, are crackling or rattling sounds signifying fluid or exudate in the lung fields. Rhonchi are a course rattling sound similar to snoring usually caused by secretion in the bronchial tree. Rubs are secretions that can be heard in the large airway.