ATI Respiratory

correct terms: -coarse grating tone -heard on inspiration and expiration -pain with breathing

A charge nurse is teaching a newly licensed nurse how to recognize a pleural friction rub. Which of the following descriptions should the nurse use to describe a pleural friction rub? (SATA)

The client is experiencing unequal movement of the posterior chest.

A nurse in the emergency department is assessing a client who has experienced thoracic trauma from a motor-vehicle crash. Which of the following findings is an indication of a pneumothorax?

Correct answer is A. (bronchial sounds are heard to the left and right of the trachea and larynx. they can only be heard on the anterior chest) (bronchovesicular breath sounds are heard from the right and left major bronchi between the first and second intercostal space on the anterior chest and also between the scapula on the posterior chest) (vesicular breath sounds are heard over a large percentage of the bilateral lung fields from the clavicle to the lower rib cage)

A nurse is auscultating the breath sounds of a client who has pneumonia and hears bronchial crackles. In which of the following areas of the chest is the nurse auscultating? (find hot spots to select in the artwork below)

correct terms: -"smoking is linked to various forms of cancer." -"it might take several attempts to finally stoop smoking." -"there are pharmacological therapies that can help a person stop smoking."

A nurse is providing teaching to a client who has a new diagnosis of asthma and reports a smoking history of 20 years. Which of the following statements should the nurse make when counseling the client about their tobacco use? (SATA)

Cheyne-Stokes breathing

A nurse is caring for a client who is dying and is having periods of deep breathing alternating with periods of apnea. The nurse should identify this as which of the following types of breathing?

1. expose the posterior chest with the client sitting with their arms folded across their chest. 2. Auscultate 8 cm (3 in) to one side of the spine around C7, then auscultate the other side of the spine in the same location. 3. Auscultate down the spine, moving the stethoscope from one side to the other until the lower thoracic spine is reached. 4. Auscultate the lateral sides slightly below the axillary area, then down to the seventh or eighth rib.

A nurse is preparing to auscultate a client's posterior and lateral chest. In which order should the nurse perform the following actions? (all steps used)

"you should make every effort to receive a flu vaccine every year." (the cdc recommends that everyone older than 6 months of age should receive an annual influenza vaccine. the flu can cause serious respiratory complications, even death, especially in those who are immunocompromised.

A nurse is providing discharge teaching to a client who has COPD regarding the influenza vaccine. Which of the following statements should the nurse make?

The nurse is auscultating through the client's gown.

A charge nurse is observing a newly licensed nurse perform an anterior chest auscultation on a client. For which of the following actions should the charge nurse intervene?

Inspiratory wheeze auscultated at left lateral chest.

A charge nurse is reviewing the documentation of a newly licensed nurse. Which of the following entries made by the newly licensed nurse is an example of correct documentation?

"Clubbing of the fingers indicates a chronic state of impaired perfusion."

A charge nurse is teaching a newly licensed nurse how to recognize manifestations of decreased oxygenation in a client. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

Correct terms: -report from client says they sleep while propped on two pillows at night. -client says they quit smoking two years ago -client states, "being short of breath all the time is making me depressed."

A nurse is admitting a client who has a new diagnosis of COPD. Which of the following information documented by the nurse is subjective data? (SATA)

Correct terms: -nail beds -oral mucosa -lips

A nurse is assessing a client who is dark-skinned. In which of the following areas of the client's body should the nurse assess the client for adequate oxygenation? (SATA)

Elevate the head of the client's bed.

A nurse is caring for a client who is having difficulty breathing. Which of the following actions should the nurse take first?

wheeze

A nurse is auscultating the lateral lobes of a client who has bronchitis. The nurse should document the sound as which of the following? (Listen to audio)

correct terms: -numbness and tingling of extremities -lightheadedness -chest pain

A nurse is caring for a client who is experiencing episodes of hyperventilation. Which of the following manifestations should the nurse expect during hyperventilation? (SATA)

correct terms: -the client is sitting in a tripod position -the client is using pursed lipped breathing -the client appears confused

A nurse is performing a head to toe assessment of a client. Which of the following findings indicate the client might be experiencing respiratory difficulty? (SATA)

A. (a barrel chest is caused by hyperinflation of the lungs due to a disease process such as copd. It can also be associated with normal aging process. the anterior/posterior transverse diameter is equal, and the ribs, normally in a downward slope, lay horizontal. the client might sit in a tripod position to obtain adequate oxygen exchange)

A nurse is reviewing the medical record of a client who was assessed as having a barrel chest resulting from COPD. Which of the following images shows a client who has a barrel chest?