Ch 19 intro to respiratory system
The clinic nurse is caring for a client who has been diagnosed with emphysema and who has just had a pulmonary function test (PFT) ordered. The client asks, "What exactly is this test for?" What would be the nurse's best response? 1) "A PFT measures whether oxygen and carbon dioxide move between your lungs and your blood." 2) "A PFT measures how much energy you get from the oxygen you breathe." 3) "A PFT measures how much air moves in and out of your lungs when you breathe." 4) "A PFT measures how elastic your lungs are."
"A PFT measures how much air moves in and out of your lungs when you breathe." Explanation: PFTs are routinely used in clients with chronic respiratory disorders. They are performed to assess respiratory function and to determine the extent of dysfunction. Such tests include measurements of lung volumes, ventilatory function, and the mechanics of breathing, diffusion, and gas exchange. Lung elasticity and diffusion can often be implied from PFTs, but they are not directly assessed. Energy obtained from respiration is not measured directly.
A 15-year-old boy with a history of asthma is undergoing lung function testing after experiencing a series of recent exacerbations. Which of the following instructions would facilitate measurement of the child's inspiratory reserve volume (IRV)? 1) "Take normal, comfortable breaths until I ask you to stop." 2) "I want you to take a normal breath in and then breathe in as deeply as you possibly can." 3) "Breathe out like you normally would and then immediately breathe out as much as you're able to." 4) "Force as much air out of your lungs as you can and then take the deepest breath that you can."
"I want you to take a normal breath in and then breathe in as deeply as you possibly can." Explanation: IRV is the maximum volume of air that can be inhaled after a normal inhalation. Consequently, the patient would be asked to inhale normally and then immediately inhale to the maximum of his or her ability.
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? 1) "The doctor will ask you to cough a few times to facilitate the insertion of the needle." 2) "If you're unable to lie on your side, you can sit upright and support yourself on your overbed table." 3) "It's very important that you remain still while the doctor is performing the procedure." 4) "You can move around as normal after the procedure is finished, and I've applied a bandage over the site."
"It's very important that you remain still while the doctor is performing the procedure." Explanation: To prevent pneumothorax, it is imperative that a patient remain immobile during thoracentesis. The patient should remain on bed rest after the procedure and should not cough during thoracentesis. The preferred positioning is with the patient upright; if this is not possible, side-lying may be used as an alternative.
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? 1) "Your doctor will probably instill a contrast solution into your lungs to aid visualization." 2) "We'll monitor you closely after the procedure, especially until your gag reflex returns." 3) "The care team will likely give you a general anesthetic for your bronchoscopy." 4) "You won't be able to swallow solid food for a day or two after the procedure."
"We'll monitor you closely after the procedure, especially until your gag reflex returns." Explanation: 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.
A client with a respiratory condition is receiving oxygen therapy. While assessing the client's PaO2, the nurse knows that the therapy has been effective based on which of the following readings? 1) 58 mm Hg 2) 84 mm Hg 3) 120 mm Hg 4) 45 mm Hg
84 mm Hg Explanation: In general, clients with respiratory conditions are given oxygen therapy only to increase the arterial oxygen pressure (PaO2) back to the client's normal baseline, which may vary from 60 to 95 mm Hg.
The ED nurse is assessing a client who is reporting dyspnea. The nurse auscultates the client's chest and hears wheezing throughout the lung fields. What might this indicate about the client? 1) Hemothorax 2) Bronchoconstriction 3) Hemoptysis 4) Pneumonia
Bronchoconstriction Explanation: Wheezing is a high-pitched, musical sound that is often the major finding in a client with bronchoconstriction or airway narrowing. Wheezing is not normally indicative of pneumonia (an infection of the lungs), hemoptysis (the expectoration of blood from the respiratory tract), or hemothorax (a collection of blood in the space between the chest wall and the lung).
What finding by the nurse may indicate that the client has chronic hypoxia? 1) clubbing 2) cyanosis 3) 4)
Clubbing of the fingers Explanation: 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. Cyanosis can be a very late indicator of hypoxia, but it is not a reliable sign of hypoxia. The other signs listed may represent only a temporary hypoxia.
The nurse is caring for an older client in the PACU. The client has had a bronchoscopy, and the nurse is monitoring for complications related to the administration of topical lidocaine. For what complication related to the administration of large doses of topical lidocaine in older adults should the nurse assess? 1) Confusion and lethargy 2) Jaundice and elevated liver enzymes 3) Decreased urine output and hypertension 4) Headache and vision changes
Confusion and lethargy Explanation : Lidocaine may be sprayed on the pharynx or dropped on the epiglottis and vocal cords and into the trachea to suppress the cough reflex and minimize discomfort during a bronchoscopy. After the procedure, the nurse will assess for confusion and lethargy in an older adult, which may be due to the large doses of lidocaine given during the procedure. The other listed signs and symptoms are not specific to this problem.
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, the client will receive home care nursing. Which information should the nurse include in discharge teaching for this client? 1) Technique for performing postural drainage 2) How to provide safe and effective tracheostomy care 3) Safe technique for self-suctioning of secretions 4) Correct and safe use of oxygen therapy equipment
Correct and safe use of oxygen therapy equipment Explanation: Respiratory care and other treatment modalities (oxygen, incentive spirometry, chest physiotherapy [CPT], and oral, inhaled, or intravenous 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 client has been diagnosed with heart failure that has not yet responded to treatment. What breath sound should the nurse expect to assess on auscultation? 1) Expiratory wheezes 2) Crackles 3) Rhonchi 4) Inspiratory wheezes
Crackles Explanation: Crackles reflect underlying inflammation or congestion and are often present in such conditions as pneumonia, bronchitis, and congestive heart failure. Rhonchi and wheezes are associated with airway obstruction, which is not a part of the pathophysiology of heart failure.
The nurse is assessing the lungs of a patient diagnosed with pulmonary edema. Which of the following would be expected upon auscultation? 1) Crackles at lung bases 2) Bronchial breath sounds 3) Absent breath sounds 4) Egophony
Crackles at lung bases Explanation: 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.
While conducting the physical examination during assessment of the respiratory system, which conditions does the nurse assess by inspecting and palpating the trachea? 1) Evidence of exudate 2) Deviation from the midline 3) Color of the mucous membranes 4) Evidence of muscle weakness
Deviation from the midline Explanation: 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.
The nurse is assessing a client who has a chest tube in place for the treatment of a pneumothorax. The nurse observes that the water level in the water seal rises and falls in rhythm with the client's respirations. How should the nurse best respond to this assessment finding? 1) Gently reinsert the chest tube 1 to 2 cm and observe if the water level stabilizes. 2) Encourage the client to do deep breathing and coughing exercises. 3) Inform the physician promptly that there is in imminent leak in the drainage system. 4) Document that the chest drainage system is operating as it is intended.
Document that the chest drainage system is operating as it is intended. Explanation: Fluctuation of the water level in the water seal shows effective connection between the pleural cavity and the drainage chamber and indicates that the drainage system remains patent. No further action is needed.
A 68-year-old male patient has been admitted to the surgical unit from the PACU after surgical repair of an inguinal hernia. When performing the patient's admission assessment, the nurse notes that the patient has a barrel chest. This assessment finding should suggest to the nurse that the patient may have a history of what health problem? 1) Chronic bronchitis 2) Tuberculosis 3) Emphysema 4) Asthma
Emphysema Explanation: Barrel chest occurs as a result of lung hyperinflation, as in emphysema. There is an increase in the anteroposterior diameter of the thorax so that it approximates a 1:1 ratio. This assessment finding is not associated with asthma, bronchitis, or tuberculosis.
A physician wants a study of diaphragmatic motion because of suspected pathology. What does the nurse anticipate that the physician will most likely order? 1) Tomogram 2) Fluoroscopy 3) Bronchogram 4) Barium swallow
Fluoroscopy Explanation: Fluoroscopy, which allows live x-ray images to be generated via a camera to a video screen, is used to assist with invasive procedures, such as a chest needle biopsy or transbronchial biopsy, that are performed to identify lesions. It also may be used to study the movement of the chest wall, mediastinum, heart, and diaphragm; to detect diaphragm paralysis; and to locate lung masses.
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 which type of impairment? 1) 2) 3) 4) Impaired gas exchange
Impaired gas exchange Explanation: 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.
Which respiratory volume is the maximum volume of air that can be inhaled after a normal exhalation? 1) Expiratory reserve volume 2) Inspiratory reserve volume 3) Residual volume 4) Tidal volume
Inspiratory reserve volume Explanation: 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 receiving 100% oxygen therapy by way of a nonrebreather mask for several days. Now the client complains of tingling in the fingers and shortness of breath, is extremely restless, and describes a pain beneath the breastbone. What should the nurse suspect? 1) Oxygen-induced atelectasis 2) Hypoxia 3) Oxygen toxicity 4) Oxygen-induced hypoventilation
Oxygen toxicity Explanation: Oxygen toxicity may occur when too high a concentration of oxygen (greater than 50%) is administered for an extended period (longer than 48 hours) (Urden, Stacy, & Lough, 2014). Signs and symptoms of oxygen toxicity include substernal discomfort, paresthesias, dyspnea, restlessness, fatigue, malaise, progressive respiratory difficulty, refractory hypoxemia, alveolar atelectasis, and alveolar infiltrates evident on chest x-rays.
The nurse is admitting a patient with COPD. The decrease of what substance in the blood gas analysis would indicate to the nurse that the patient is experiencing hypoxemia? 1) HCO3 2) pH 3) PaO2 4) PCO2
PaO2 Explanation: Hypoxemic hypoxia, or hypoxemia, is a decreased oxygen level in the blood (PaO2) resulting in decreased oxygen diffusion into the tissues.
The nurse is discussing activity management with a client who is postoperative following thoracotomy. What instructions should the nurse give to the client regarding activity immediately following discharge? 1) Use weights daily to increase arm strength. 2) Walk 1 mile (1.6 km) 3 to 4 times a week. 3) Perform shoulder exercises five times daily. 4) Walk on a treadmill 30 minutes daily.
Perform shoulder exercises five times daily. Explanation: The nurse emphasizes the importance of progressively increased activity. The nurse also instructs the client on the importance of performing shoulder exercises five times daily. The client should ambulate with limits and realize that the return of strength will likely be gradual and likely will not include weight lifting or lengthy walks.
The nurse reviews the results of a client's ventilation-perfusion (V/Q) scan. For which condition will the nurse plan care when the ventilation-perfusion ratio is less than 0.80? 1) Pulmonary emboli 2) Pneumonia 3) Cardiogenic shock 4) Pulmonary infarction
Pneumonia Explanation: Adequate gas exchange depends on an adequate ventilation-perfusion (V̇/Q̇) ratio. In different areas of the lung, the (V̇/Q̇) ratio varies. V̇/Q̇ imbalance occurs as a result of inadequate ventilation, inadequate perfusion, or both. Low ventilation-perfusion states may be called shunt-producing disorders. When perfusion exceeds ventilation, a shunt exists . Blood bypasses the alveoli without gas exchange occurring. This is seen with obstruction of the distal airways, such as with pneumonia, atelectasis, tumor, or a mucus plug. In the absence of both ventilation and perfusion or with limited ventilation and perfusion, a condition known as a silent unit occurs. This is seen with pneumothorax and severe acute respiratory distress syndrome. When ventilation exceeds perfusion, dead space results. The alveoli do not have an adequate blood supply for gas exchange to occur. This is characteristic of a variety of disorders, including pulmonary emboli, pulmonary infarction, and cardiogenic shock.
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? 1) Infective process 2) Atelectasis 3) Tumor 4) Pulmonary embolism
Pulmonary embolism Explanation: 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 client with chronic bronchitis is admitted to the health facility. Auscultation of the lungs reveals low-pitched, rumbling sounds. Which term should the nurse document? 1) Crackles 2) Pleural friction rub 3) Rhonchi 4) Bronchial
Rhonchi Explanation: Rhonchi or sonorous wheezes are deep, low-pitched, rumbling sounds heard usually on expiration. The etiology of rhonchi is associated with chronic bronchitis. Crackles are soft, high-pitched sounds. Pleural friction rub is a creaking or grating sound not affected by coughing. Bronchial sounds are relatively high-pitched sounds.
The nurse is caring for a client who has a pleural effusion and who underwent a thoracoscopic procedure earlier in the morning. The nurse should prioritize assessment for which of the following? 1) Sputum production 2) Epistaxis 3) Throat discomfort 4) Shortness of breath
Shortness of breath Explanation: Thoracoscopy is a diagnostic procedure in which the pleural cavity is examined with an endoscope and fluid and tissues can be obtained for analysis. Follow-up care in the health care facility and at home involves monitoring the client for shortness of breath (which might indicate a pneumothorax). All of the listed options are relevant assessment findings, but shortness of breath is the most serious complication.
The home care nurse is visiting a client newly discharged home after a lobectomy. What would be most important for the home care nurse to assess? 1) Nutritional status and fluid balance 2) The family's willingness to care for the client 3) Signs and symptoms of respiratory complications 4) Resumption of the client's ADLs
Signs and symptoms of respiratory complications Explanation: The nurse assesses the client's adherence to the postoperative treatment plan and identifies acute or late postoperative complications. All options presented need assessment, but respiratory complications are the highest priority because they most directly affect the client's airway and breathing.
In which position should the client be placed for a thoracentesis? 1) Sitting on the edge of the bed 2) Supine 3) Prone 4) Lateral recumbent
Sitting on the edge of the bed Explanation: 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 critical care nurse and the other members of the care team are assessing the client to see if the client is ready to be weaned from the ventilator. What are the most important predictors of successful weaning that the nurse should identify? 1) Stable vital signs and arterial blood gases (ABGs) 2) Normal level of consciousness 3) Stable nutritional status and ABGs 4) Pulse oximetry above 80% and stable vital signs
Stable vital signs and arterial blood gases (ABGs) Explanation: Among many other predictors, stable vital signs and ABGs are important predictors of successful weaning. Pulse oximetry must greatly exceed 80%. Nutritional status is important, but vital signs and ABGs are even more significant. Clients who are weaned may or may not have normal level of consciousness.
While assessing the client, the nurse observes constant bubbling in the water-seal chamber of the client's closed chest-drainage system. Which conclusion should the nurse reach? 1) The client has a pneumothorax. 2) The chest tube is obstructed. 3) The system has an air leak. 4) The system is functioning normally.
The system has an air leak. Explanation: The water-seal chamber of a wet chest drainage system has a one-way valve or water seal that prevents air from moving back into the chest when the client inhales. There is an increase in the water level with inspiration and a return to the baseline level during exhalation; this is referred to as tidaling. Intermittent bubbling in the water-seal chamber is normal, but continuous bubbling can indicate an air leak, which requires immediate assessment and intervention. The client with a pneumothorax will have intermittent bubbling in the water-seal chamber. If the tube is obstructed, the nurse should notice that the fluid has stopped fluctuating in the water-seal chamber.
A client with chronic lung disease is undergoing lung function testing. What test result denotes the volume of air inspired and expired with a normal breath? 1) Total lung capacity 2) Tidal volume 3) Residual volume 4) Forced vital capacity
Tidal volume Explanation: Tidal volume refers to the volume of air inspired and expired with a normal breath. Total lung capacity is the maximal amount of air the lungs and respiratory passages can hold after a forced inspiration. Forced vital capacity is vital capacity performed with a maximally forced expiration. Residual volume is the maximal amount of air left in the lung after a maximal expiration.
Which term refers to the volume of air inhaled or exhaled during each respiratory cycle? 1) Functional residual capacity 2) Tidal volume 3) Vital capacity 4) Maximal voluntary ventilation
Tidal volume Explanation: Tidal volume refers to the volume of air inhaled or exhaled during each respiratory cycle when breathing normally. Normal tidal volume ranges from 400 to 700 ml. Vital capacity refers to the total volume of air that can be exhaled during a slow, maximal expiration after maximal inspiration. Functional residual capacity refers to the volume of air remaining in the lungs after a normal expiration. Maximal voluntary ventilation is the greatest volume of air expired in 1 minute with maximal voluntary effort.
A client with a decreased level of consciousness is in a recumbent position. How should the nurse best assess the lung fields for a client in this position? 1) Review images from the client's portable chest x-ray. 2) Assess the breath sounds accessible from the anterior chest wall. 3) Turn the client to enable assessment of all lung fields. 4) Assess oxygen saturation and, if low, reposition the client and auscultate breath sounds.
Turn the client to enable assessment of all lung fields. Explanation: Assessment of the anterior and posterior lung fields is part of the nurse's routine evaluation. If the client is recumbent, it is essential to turn the client to assess all lung fields so that dependent areas can be assessed for breath sounds, including the presence of normal breath sounds and adventitious sounds. Failure to examine the dependent areas of the lungs can result in missing significant findings. A chest x-ray does not allow assessment of breath sounds. Assessment of only breath sounds accessible from the anterior chest wall neglects breath sounds that can only be assessed in other lung fields. All lung fields need to be assessed whether oxygen saturation is low or not.
A nurse is assessing a client's respiratory system. Which alveolar cells secrete surfactant to reduce lung surface tension? 1) Type I 2) Type II 3) Macrophages 4) Type IV
Type II Explanation: 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 is discussing squamous epithelial cells lining each alveolus, which consist of different types of cells. Which type of alveolar cells produce surfactant? 1) Type II cells 2) Type III cells 3) Type IV cells 4) Type I cells
Type II cells Explanation: 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. The epithelium of the alveoli does not contain Type IV cells.
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? 1) Crackles 2) Wheezes 3) Rales 4) Rhonchi
Wheezes Explanation: 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.
In addition to heart rate, blood pressure, respiratory rate, and temperature, the nurse needs to assess a client's arterial oxygen saturation (SaO2). What procedure will best accomplish this? 1) Incentive spirometry 2) Arterial blood gas (ABG) measurement 3) Pulse oximetry 4) Peak flow measurement
Pulse oximetry Explanation: Pulse oximetry is a noninvasive procedure in which a small sensor is positioned over a pulsating vascular bed. It can be used during transport and causes the client no discomfort. An incentive spirometer is used to assist the client with deep breathing after surgery. ABG measurement can measure SaO2, but this is an invasive procedure that can be painful. Some clients with asthma use peak flow meters to measure levels of expired air.
