Ch 19: Intro to Respiratory System

A client is having her tonsils removed. The client asks the nurse what function the tonsils normally serve. Which of the following would be the most accurate response?

"The tonsils help to guard the body from invasion of organisms." Reasoning: 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, separate the trachea from the esophagus, or regulate airflow to the bronchi.

Computed tomography of a patient's chest is suggestive of a malignancy, but these results are not conclusive. As a result, the patient has been scheduled for a bronchoscopy. What patient education should the nurse provide for this patient regarding this diagnostic procedure?

"We'll monitor you closely after the procedure, especially until your gag reflex returns." Reasoning: After a bronchoscopy, 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. However, this normally takes a few hours, not one or two days. Bronchoscopy is normally performed under conscious sedation. Contrast solution is not used.

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 nurse's hands move down the client's thorax Reasoning: 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.

The ED nurse is assessing the respiratory function of a teenage girl who presented with acute shortness of breath. Auscultation reveals continuous wheezes during inspiration and expiration. This finding is most suggestive of what?

Asthma Reasoning: Sibilant wheezes are commonly associated with asthma. They do not normally accompany pleurisy, emphysema, or pneumonia.

A thoracentesis is performed to obtain a sample of pleural fluid or a biopsy specimen from the pleural wall for diagnostic purposes. What does serous fluid indicate?

Cancer Reasoning: A thoracentesis may be performed to obtain a sample of pleural fluid or to biopsy a specimen from the pleural wall for diagnostic purposes. Bloody fluid typically suggests trauma. Purulent fluid is diagnostic for infection. Serous fluid may be associated with cancer, inflammatory conditions, or heart failure. Complications that may follow a thoracentesis include pneumothorax and subcutaneous emphysema.

"Swallowing down the wrong pipe" typically causes a significant coughing spasm and gasping for air, followed by recovery. Which upper airway structure malfunctions to cause the event?

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

The nurse is caring for a client with a lower respiratory tract infection. When planning a focused respiratory assessment, the nurse should know that this type of infection most often causes what?

Impaired gas exchange Reasoning: 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 necrosis of lung tissues.

A client is scheduled to have excess pleural fluid aspirated with a needle in order to relieve her dyspnea. The client inquires about the normal function of pleural fluid. What should the nurse describe?

It lubricates the movement of the thorax and lungs. Reasoning: The visceral pleura cover the lungs; the parietal pleura line the thorax. The visceral and parietal pleura and the small amount of pleural fluid between these two membranes serve to lubricate the thorax and lungs and permit smooth motion of the lungs within the thoracic cavity with each breath. The pleura do not allow full expansion of the lungs, prevent the lungs from collapsing, or limit lung expansion within the thoracic cavity.

A critical care nurse is caring for a client with an endotracheal tube who is on a ventilator. The nurse knows that meticulous airway management of this client is necessary. What is the main rationale for this?

Maintaining a patent airway Reasoning: Maintaining a patent (open) airway is achieved through meticulous airway management, whether in an emergency situation such as airway obstruction or in long-term management, as in caring for a client with an endotracheal or a tracheostomy tube. Airway management is not primarily conducted to reduce the need for suctioning, to maintain sterility or to increase compliance because none of these are important if the client's airway is not patent.

The nurse is assessing a client who frequently coughs after eating or drinking. How should the nurse best follow up this assessment finding?

Perform a swallowing assessment. Reasoning: Coughing after food intake may indicate aspiration of material into the tracheobronchial tree; a swallowing assessment is thus indicated. Obtaining a sputum sample is relevant in cases of suspected infection. The status of the client's tongue, mouth, and nutrition is not directly relevant to the problem of aspiration.

A client has been diagnosed with pulmonary hypertension, in which the capillaries in the alveoli are squeezed excessively. The nurse should recognize a disturbance in what aspect of normal respiratory function?

Perfusion Reasoning: Perfusion is influenced by alveolar pressure. The pulmonary capillaries are sandwiched between adjacent alveoli and, if the alveolar pressure is sufficiently high, the capillaries are squeezed. This does not constitute a disturbance in ventilation (air movement), diffusion (gas exchange), or acid-base balance.

Which ventilation-perfusion ratio is exhibited by acute respiratory distress syndrome (ARDS)?

Silent Unit Reasoning: When ventilation exceeds perfusion a dead space exists. An example of a dead space is a pulmonary emboli. A low ventilation-perfusion ratio exists in pneumonia or with a mucus plug. A silent unit occurs in pneumothorax or ARDS.

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

Swallow reflex Reasoning: 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.

Which type of ventilator has a preset volume of air to be delivered with each inspiration?

Volume Cycled Reasoning: With volume-cycled ventilation, the volume of air to be delivered with each inspiration is preset. Negative-pressure ventilators exert a negative pressure on the external chest. Time-cycled ventilators terminate or control inspiration after a preset time. When the pressure-cycled ventilator cycles on, it delivers a flow of air (inspiration) until it reaches a preset pressure, and then cycles off, and expiration occurs passively.

The nurse is caring for a client who has been scheduled for a bronchoscopy. How should the nurse prepare the client for this procedure?

Withhold food and fluids for several hours before the test. Reasoning: Food and fluids are withheld for 4 to 8 hours before the test to reduce the risk of aspiration when the cough reflex is blocked by anesthesia. IV fluids, bronchodilators, and a central line are unnecessary.

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

sitting on the edge of the bed Reasoning: 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 assesses a patient with a heart rate of 42 and a blood pressure of 70/46. What type of hypoxia does the nurse determine this patient is displaying?

Circulatory hypoxia Reasoning: Given the vital signs, this client appears to be in shock. Circulatory hypoxia results from inadequate capillary circulation and may be caused by decreased cardiac output, local vascular obstruction, low-flow states such as shock, or cardiac arrest. Although tissue partial pressure of oxygen (PO2) is reduced, arterial oxygen (PaO2) remains normal. Circulatory hypoxia is corrected by identifying and treating the underlying cause. The low blood pressure is consistent with circulatory hypoxia but not consistent with the other options. Anemic hypoxia is a result of decreased effective hemoglobin concentration. Histotoxic hypoxia occurs when a toxic substance interferes with the ability of tissues to use available oxygen. Hypoxemic hypoxia results from a low level of oxygen in the blood.

The nurse is preparing to discharge a client after thoracotomy. The client is going home on oxygen therapy and requires wound care. As a result, he will receive home care nursing. What should the nurse include in discharge teaching for this client?

Correct and safe use of oxygen therapy equipment Reasoning: Respiratory care and other treatment modalities (oxygen, incentive spirometry, chest physiotherapy [CPT], and oral, inhaled, or IV medications) may be continued at home. Therefore, the nurse needs to instruct the client and family in their correct and safe use. The scenario does not indicate the client needs help with suctioning, postural drainage, or tracheostomy care.

A nurse is teaching a client about the functions of the larynx. What should the nurse include in the teaching? Select all that apply.

Producing sound Facilitating coughing Protecting the lower airway from foreign objects Reasoning: The larynx, or voice box, is a cartilaginous framework between the pharynx and trachea. Its primary function is to produce sound. The larynx assists in protecting the lower airway. Facilitating coughing is a function of the larynx. Preventing infection is the main function of the tonsils and adenoids. The pharynx is a passage way for the respiratory tract.

A client has been discharged home after thoracic surgery. The home care nurse performs the initial visit and finds the client discouraged and saddened. The client states, "I am recovering so slowly. I really thought I would be better by now." What nursing action should the nurse prioritize?

Provide emotional support to the client and family. Reasoning: The recovery process may take longer than the client had expected, and providing support to the client is an important task for the home care nurse. It is not necessary, based on this scenario, to schedule a visit with the physician within 24 hours, or to get a referral to a psychiatrist or a social worker.