Ch 20: Assessment of Respiratory Function

count the rate of respirations

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

the pons

A client experiences a head injury in a motor vehicle accident. The client's level of consciousness is declining, and respirations have become slow and shallow. When monitoring a client's respiratory status, which area of the brain would the nurse realize is responsible for the rate and depth?

lungs are clear on auscultation

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?

diaphragm contracts and elongates the chest cavity

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 only complete cartilaginous ring in the larynx

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

sitting on the edge of the bed

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

5 g/dL

Inspection of a patient's skin color is part of the assessment of the integumentary system. Cyanosis, which is a late indicator of hypoxia, is present when the unoxygenated hemoglobin level is:

pulmonary edema

Pink, frothy sputum may be an indication of

respiratory distress

The client has just had an invasive procedure to assess the respiratory system. What does the nurse know should be assessed on this client?

infection

What would the instructor tell the students purulent fluid indicates?

the nursing assistant is pouring a glass of water to wet the client's mouth

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?

no sensation during palpation

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

clubbing of the fingers

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

producing sound

What is the primary function of the larynx?

warm and humidify inspired air

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

trachea

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

air is drawn through the trachea and bronchi into the alveoli during inspiration

Which is a true statement regarding air pressure variances?

difficulty in breathing

Which of the following clinical manifestations should a nurse monitor for during a pulmonary angiography, which indicates an allergic reaction to the contrast medium?

tidal volume

Which term refers to the volume of air inhaled or exhaled during each respiratory cycle?

ronchi

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?

respiratory rate of 44 breaths per minute

A nurse is caring for a client after a lung biopsy. Which assessment finding requires immediate intervention?

impaired gas exchange

A nurse is concerned that a client may develop postoperative atelectasis. Which nursing diagnosis would be most appropriate if this complication occurs?

type II 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?

pleurisy

A patient describes his chest pain as knife-like on inspiration. Which of the following is the most likely diagnosis?

asthma

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?

pleural friction rub

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

diagnosis of peripheral vascular disease

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?

swallow reflex

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

how these issues affect the client's quality of life

You are assessing the respiratory system of a client just admitted to your unit. What do you know to assess in addition to the physical and functional issues related to breathing?

is breathing air in and out of the lungs

A client has been newly diagnosed with emphysema. The nurse should explain to the client that by definition, ventilation:

bronchophony

A nurse is performing a respiratory assessment on a client with pneumonia. She asks the client to say "ninety-nine" several times. Through her stethoscope, she hears the words clearly over his left lower lobe. What term should the nurse use to document this finding?

do not eat or drink for 6 hours before the procedure

A nurse is preparing a client for bronchoscopy. Which instruction should the nurse give to the client?

on the cheeks below the eyes

A nurse practitioner diagnosed a patient with an infection in the maxillary sinuses. Select the area that the nurse palpated to make that diagnosis.

absent distal pulses

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?

MRI can view soft tissues and can help stage cancers

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)?

they can be heard during inspiration and expiration

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?

asking the client to repeat "ninety-nine" as the nurse's hands move down the client's thorax

The nurse is caring for a client diagnosed with pneumonia. The nurse assesses the client for tactile fremitus by completing which action?

assess the client for a cough reflex

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?

iodine allergy

The nurse is in the radiology unit of the hospital. The nurse is caring for a client who is scheduled for a lung scan. The nurse knows that lung scans need the use of radioisotopes and a scanning machine. Before the perfusion scan, what must the client be assessed for?

take deep breaths and cough forcefully

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?

dead space

Which ventilation-perfusion ratio is exhibited by a pulmonary embolus?