Ch 20: Assessment of Respiratory Function (3)
The nurse is caring for a client who is to undergo a thoracentesis. In preparation for the procedure, the nurse places the client in which position? pg. 507
Sitting on the edge of the bed
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? pg. 505
"I will feel warm and may have chest pain"
A nurse would question the accuracy of a pulse oximetry evaluation in which of the following conditions? pg. 503
A client experiencing hypothermia
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? pg. 500
Asthma
While conducting the physical examination during assessment of the respiratory system, which conditions does the nurse assess by inspecting and palpating the trachea? pg. 493
Deviation from the midline
A pediatrician diagnosed a child with swollen and inflamed adenoids. The nurse practitioner confirmed the diagnosis by: pg. 481
Inspecting the roof of the nasopharynx.
The nurse is caring for a client in the immediate post-thoracentesis period. In which position is the client placed? pg. 507
Lying on the unaffected side
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? pg. 499
They can be heard during inspiration and expiration.
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? pg. 486
Ventilation exceeds perfusion.
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? pg. 505
Absent distal pulses
Which is a true statement regarding air pressure variances? pg. 484
Air is drawn through the trachea and bronchi into the alveoli during inspiration.
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. pg. 484
Diaphragm contracts and elongates the chest cavity.
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? pg. 500
Dull
A nurse is concerned that a client may develop postoperative atelectasis. Which nursing diagnosis would be most appropriate if this complication occurs? pg. 500
Impaired gas exchange
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? pg. 498
Lungs are clear on auscultation.
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)? pg. 504
MRI can view soft tissues and can help stage cancers.
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? pg. 490
Pleurisy
The clinical finding of pink, frothy sputum may be an indication of which condition? pg. 490
Pulmonary edema
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? pg. 499
Rhonchi
Pink, frothy sputum may be an indication of pg. 490
pulmonary edema.
