Ch. 20 Resp func N327
You are caring for a client admitted with chronic bronchitis. The client is having difficulty breathing, and the family asks you what causes this difficulty. What would be your best response?
"Conditions such as chronic bronchitis cause thickening of the bronchial mucosa so it makes it harder to breathe."
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?
"I will feel warm and may have chest pain"
The nurse is completing a physical assessment of a client's trachea. The nurse inspects and palpates the trachea for
deviation from the midline.
Normally, approximately what percentage of the blood pumped by the right ventricle does not perfuse the alveolar capillaries?
2%
A nurse would question the accuracy of a pulse oximetry evaluation in which of the following conditions?
A client experiencing hypothermia
A client with exacerbation of chronic obstructive pulmonary disease (COPD) is scheduled for a thoracentesis. Which nursing intervention would be appropriate for client safety?
Administering a cough suppressant as needed
Which is a true statement regarding air pressure variances?
Air is drawn through the trachea and bronchi into the alveoli during inspiration.
The nurse auscultated a patient's middle lobe of the lungs for abnormal breath sounds. To do this, the nurse placed the stethoscope on the:
Anterior surface of the right side of the chest, between the fourth and fifth rib.
A nurse assesses a client with crackles. What medical condition should the nurse suspect? Select all that apply.
Asthma Chronic bronchitis A collapsed alveoli Pulmonary fibrosis
The nurse inspects the thorax of a patient with advanced emphysema. What does the nurse expect the chest configuration to be for this patient?
Barrel chest
Which is a deformity of the chest that occurs as a result of overinflation of the lungs?
Barrel chest
Which assessment finding would be most consistent with advanced emphysema?
Barrel-shaped chest
In a patient diagnosed with increased intracranial pressure (IICP), the nurse would expect to observe which of the following respiratory rate or depth?
Bradypnea
What finding by the nurse may indicate that the client has chronic hypoxia?
Clubbing of the fingers
The nurse auscultates crackles in a patient with a respiratory disorder. With what disorder would crackles be commonly heard?
Collapsed alveoli
A client appears to be breathing faster than during the last assessment. Which of the following interventions should the nurse perform?
Count the rate of respirations.
When the nurse is assessing the older adult patient, what gerontologic changes in the respiratory system should the nurse be aware of? (Select all that apply.)
Decreased gag reflex Increased presence of collagen in alveolar walls Decreased presence of mucus Chapter 20: Assessment of Respiratory Function - Page 488 Age-related changes in the respiratory system include a decrease in mucus, decrease in gag reflex, increase in collagen in the alveolar walls of the lungs, and increase in alveolar duct diameter.
A nurse is preparing a client for bronchoscopy. Which instruction should the nurse give to the client?
Do not eat or drink for 6 hours before the procedure.
During a preadmission assessment, for what diagnosis would the nurse expect to find decreased tactile fremitus and hyperresonant percussion sounds?
Emphysema
A client arrived in the emergency department with a sharp object penetrating the diaphragm. When planning nursing care, which nursing diagnosis would the nurse identify as a priority?
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?
Impaired gas exchange
Which of the following is an age-related change associated with the lung?
Increased thickness of the alveolar membranes
What would the instructor tell the students purulent fluid indicates?
Infection
A pediatrician diagnosed a child with swollen and inflamed adenoids. The nurse practitioner confirmed the diagnosis by:
Inspecting the roof of the nasopharynx.
Which respiratory volume is the maximum volume of air that can be inhaled after maximal expiration?
Inspiratory reserve volume
What happens to the diaphragm during inspiration?
It contracts and flattens.
A patient diagnosed with diabetic ketoacidosis would be expected to have which type of respiratory pattern?
Kussmaul respirations
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?
Lungs are clear on auscultation.
The nurse is caring for a client in the immediate post-thoracentesis period. In which position is the client placed?
Lying on the unaffected side
Upon palpation of the sinus area, what would the nurse identify as a normal finding?
No sensation during palpation
The student nurse is learning breath sounds while listening to a client in the physician's office. An experienced nurse is assisting and notes air movement over the trachea to the upper lungs. The air movement is noted equally on inspiration as expiration. Which breath sounds would the nurse document?
Normal bronchovesicular sounds
A nurse practitioner diagnosed a patient with an infection in the maxillary sinuses. Select the area that the nurse palpated to make that diagnosis.
On the cheeks below the eyes
When assessing a client, which adaptation indicates the presence of respiratory distress?
Orthopnea
The nurse is reviewing the blood gas results for a patient with pneumonia. What arterial blood gas measurement best reflects the adequacy of alveolar ventilation?
PaCO2
The nurse is taking a respiratory history for a patient who has come into the clinic with a chronic cough. What information should the nurse obtain from this patient? (Select all that apply.)
Previous history of lung disease in the patient or family Occupational and environmental influences Previous history of smoking
What is the primary function of the larynx?
Producing sound
A student nurse is working with a client who is diagnosed with head trauma. The nurse has documented Cheyne-Stokes respirations. The student would expect to see which of the following?
Regular breathing where the rate and depth increase, then decrease
Which of the following ventilation-perfusion mismatch would correlate with acute respiratory distress syndrome (ARDS)?
Silent unit
Which ventilation-perfusion ratio is exhibited by acute respiratory distress syndrome (ARDS)?
Silent unit
The nurse is admitting a client who just had a bronchoscopy. Which assessment should be the nurse's priority?
Swallow reflex
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?
The nursing assistant is pouring a glass of water to wet the client's mouth.
In relation to the structure of the larynx, which describes the cricoid cartilage?
The only complete cartilaginous ring in the larynx
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?
The pons
Which term refers to the volume of air inhaled or exhaled during each respiratory cycle?
Tidal volume
A nurse is assessing a client's respiratory system. Which alveolar cells secrete surfactant to reduce lung surface tension?
Type II
A nurse is discussing squamous epithelial cells lining each alveolus, which consist of different types of cells. Which type of alveolar cells produce surfactant?
Type II cells
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?
Ventilation exceeds perfusion.
The nurse is caring for a client with a decrease in airway diameter causing airway resistance. The client experiences coughing and mucus production. Upon lung assessment, which adventitious breath sounds are anticipated?
Wheezes
A client is chronically short of breath and yet has normal lung ventilation, clear lungs, and an arterial oxygen saturation SaO2 of 96% or better. The client most likely has:
a possible hematologic problem.
Understanding pulmonary physiology, what characteristic would the nurse expect to result in decreased gas exchange in older adults?
alveolar walls containing fewer capillaries
The nurse answers a client's call light. The client reports an irritating tickling sensation in the throat, a salty taste, and a burning sensation in the chest. Upon further assessment, the nurse notes a tissue with bright red, frothy blood at the bedside. The nurse can assume the source of the blood is likely from the
lungs.
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
pleural friction rub.
In relation to the structure of the larynx, the cricoid cartilage is
the only complete cartilaginous ring in the larynx.
The amount of air inspired and expired with each breath is called:
tidal volume.
The term for the volume of air inhaled and exhaled with each breath is
tidal volume.
A nurse enters a client's room and observes a container with sputum. Upon questioning about the specimen, which information from the client would necessitate the nurse to obtain a new specimen?
"I coughed that up about 8 hours ago."
The nurse is caring for a client with an exacerbation of COPD and scheduled for pulmonary function studies using a spirometer. Which client statement would the nurse clarify?
"I will breathe in through my mouth and out through my nose."
A nurse understands that a safe but low level of oxygen saturation provides for adequate tissue saturation while allowing no reserve for situations that threaten ventilation. What is a safe but low oxygen saturation level for a patient?
95% Chapter 20: Assessment of Respiratory Function - Page 503 Normal SpO2 values are more than 95%. Values less than 90% indicate that the tissues are not receiving enough oxygen, in which case further evaluation is needed.
The nurse inspects the thorax of a patient with advanced emphysema. The nurse expects chest configuration changes consistent with a deformity known as:
Barrel chest
The nurse is caring for a patient with a pulmonary disorder. What observation by the nurse is indicative of a very late symptom of hypoxia?
Cyanosis
Which is a late sign of hypoxia?
Cyanosis
Which ventilation-perfusion ratio is exhibited in a client diagnosed with a pulmonary embolus?
Dead space
While assessing for tactile fremitus, the nurse palpates almost no vibration. Which of the following conditions in this client's history will account for this finding?
Emphysema
A nurse is caring for an older adult with pneumonia. What are age-related structural and functional changes that occur in the respiratory system? Select all that apply.
Decreased elasticity of the alveolar sacs Increased residual volume Increased diameter of alveolar ducts Increased thickness of alveolar sacs Chapter 20: Assessment of Respiratory Function - Page 489 Decreased elasticity of the alveolar sacs, increased residual volume, increased diameter of alveolar ducts, and increased thickness of alveolar sacs are age-related changes in the respiratory system. Pulmonary compliance increases with aging. Dead space increases with aging.
Which of the following clinical manifestations should a nurse monitor for during a pulmonary angiography, which indicates an allergic reaction to the contrast medium?
Difficulty in breathing
High or increased compliance occurs in which disease process?
Emphysema Chapter 20: Assessment of Respiratory Function - Page 484 High or increased compliance occurs if the lungs have lost their elasticity and the thorax is overdistended, as in emphysema. Conditions associated with decreased compliance include pneumothorax, pleural effusion, and acute respiratory distress syndrome (ARDS).
A patient with sinus congestion points to a location on the inside of his eye as the area of pain. The nurse documents that the patient is complaining of pain in which sinus?
Ethmoid
The Family Nurse Practitioner is performing a physical examination of a client. The Nurse Practitioner examines the client's anterior, posterior, and lateral chest walls. What is the Nurse Practitioner assessing?
Evidence of muscle weakness
A client with sinus congestion complains of discomfort when the nurse is palpating the supraorbital ridges. What sinus is the client referring?
Frontal
A client has just undergone bronchoscopy. Which nursing assessment is most important at this time?
Level of consciousness
On arrival at the intensive care unit, a critically ill client suffers respiratory arrest and is placed on mechanical ventilation. The physician orders pulse oximetry to monitor the client's arterial oxygen saturation (SaO2) noninvasively. Which vital sign abnormality may alter pulse oximetry values?
Hypotension
The nurse is caring for a critically ill client in the ICU. The nurse documents the client's respiratory rate as bradypnea. The nurse recognizes that bradypnea is associated with which condition?
Increased intracranial pressure
A client presents to the ED reporting severe coughing episodes. The client states that "the episodes are more intense at night." The nurse should suspect which of the following conditions based on the client's primary report?
Left-sided heart failure
A young adult visited a clinic because he was injured during a softball game. He told the nurse that the ball struck him in his "Adam's apple." To assess the initial impact of injury, the nurse:
Palpates the thyroid cartilage.
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?
Pleurisy
A patient describes his chest pain as knife-like on inspiration. Which of the following is the most likely diagnosis?
Pleurisy
During a preadmission assessment, the nurse finds increased tactile fremitus. She knows this sign is consistent with which of the following diagnoses?
Pneumonia
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?
Pulmonary embolism
The nurse is caring for a client whose respiratory status has declined since shift report. The client has tachypnea, is restless, and displays cyanosis. Which diagnostic test should be assessed first?
Pulse oximetry
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?
Sitting on the edge of the bed
A nurse is caring for a client who has frequent upper respiratory infections. Which structure is most helpful in protecting against infection?
Tonsils
The nurse is caring for a client who is scheduled for a bronchoscopy. The nurse understands that it is important to provide the required information and appropriate explanations for any diagnostic procedure to a client with a respiratory disorder in a way that
manages decreased energy levels.
A black client with asthma seeks emergency care for acute respiratory distress. Because of this client's dark skin, the nurse should assess for cyanosis by inspecting the:
mucous membranes.
A client has recently been diagnosed with malignant lung cancer. The nurse is calculating the client's smoking history in pack-years. The client reports smoking two packs of cigarettes a day for the past 11 years. The nurse correctly documents the client's pack-years as
22.
High or increased compliance occurs in which condition?
Emphysema
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?
Iodine allergy
The nurse is caring for a client with suspected lung cancer. Which imaging study is more accurate than computed tomography in detecting malignancies?
PET
The clinical finding of pink, frothy sputum may be an indication of which condition?
Pulmonary edema
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:
5 g/dL
Which of the following disease processes cause increased compliance?
Emphysema
A nonverbal client has just finished undergoing a bronchoscopy procedure and writes that he want to eat lunch now. Which intervention is necessary for the nurse to complete at this time?
Assess 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?
Assess the client for a cough reflex.
A nurse is instructing a client who is scheduled for a perfusion lung scan. What teaching should the nurse include in the information about the procedure? Select all that apply.
A mask will be placed over the nose and mouth during the test. The client will be expected to lie under the camera. The imaging time will amount to 20 to 40 minutes.
The nurse is caring for a client who is in respiratory distress. The physician orders arterial blood gases (ABGs) to determine various factors related to blood oxygenation. What site can ABGs be obtained from?
A puncture at the radial artery
The nurse is caring for an adolescent client injured in a snowboarding accident. The client has a head injury, a fractured right rib, and various abrasions and contusions. The client has a blood pressure of 142/88 mm Hg, pulse of 102 beats/minute, and respirations of 26 breaths/minute. Which laboratory test best provides data on a potential impairment in ventilation?
Blood gases
The nurse is assessing a patient in respiratory failure. What finding is a late indicator of hypoxia?
Cyanosis
The nurse is caring for a client with extensive respiratory disease. Which is a late sign of hypoxia the client may experience?
Cyanosis
Which ventilation-perfusion ratio is exhibited in a client diagnosed with a pulmonary embolus?
Dead space Chapter 20: Assessment of Respiratory Function - Page 486 A dead space exists when ventilation exceeds perfusion (high ventilation-perfusion ratios). An example of a dead space is a pulmonary embolus, pulmonary infarction, and cardiogenic shock. A low ventilation-perfusion ratio exists in pneumonia or with a mucus plug. A silent unit occurs in pneumothorax or acute respiratory distress syndrome.
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?
Dull
A client has suspected fluid accumulation in the pleural space of the lungs and is scheduled for a thoracentesis. The nurse will implement which of the following for this procedure? Select all that apply.
Educate the client about the need to cleanse the thoracic area. Apply pressure to the puncture site after the procedure. Complete a respiratory assessment after the procedure.
The nurse knows that what condition is associated with increased compliance of the lungs?
Emphysema
During a routine visit to the pulmonologist, a client is told to undergo a mediastinoscopy. After the physician leaves the room, the nurse enters and is asked about this procedure. How should the nurse respond?
Exploration and biopsy of the lymph nodes that drain the lungs
A physician wants a study of diaphragmatic motion because of suspected pathology. What does the nurse anticipate that the physician will most likely order?
Fluoroscopy
Which of the following is a noninvasive method of continuously monitoring the oxygen saturation of hemoglobin (SaO2)?
Pulse oximetry Chapter 20: Assessment of Respiratory Function - Page 503 Pulse oximetry is a noninvasive method of continuously monitoring SaO2. Measurements of blood pH of arterial oxygen and carbon dioxide tensions are obtained when managing patients with respiratory problems and adjusting oxygen therapy as needed. This is an invasive procedure. Pulmonary function testing assesses respiratory function and determines the extent of dysfunction. Sputum studies are done to identify if any pathogenic organisms or malignant cells are in the sputum.
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?
Rhonchi
An client is described as having pectus carinatum. What would be the physical manifestation of this condition?
The sternum protrudes and the ribs are sloped backward. Chapter 20: Assessment of Respiratory Function - Page 495 Also known as pigeon chest, in this congenital anomaly, the sternum abnormally protrudes and the ribs are sloped backward. A depressed sternum would be considered funnel chest, or pectus excavatum. S-shaped spinal curvature would be considered scoliosis. A rounded chest would be considered barrel chest in which the anteroposterior diameter increases to equal the transverse diameter.
What is the purpose of the vascular and ciliated mucous lining of the nasal cavities?
Warm and humidify inspired air
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?
Absent distal pulses Chapter 20: Assessment of Respiratory Function - Page 505 When monitoring clients after a pulmonary angiography, nurses must notify the health care provider about diminished or absent distal pulses, cool skin temperature in the affected limb, and poor capillary refill. When the contrast medium is infused, the client will sense a warm, flushed feeling.
Your client is scheduled for a bronchoscopy to visualize the larynx, trachea, and bronchi. What precautions would you recommend to the client before the procedure?
Abstain from food for at least 6 hours before the procedure.
A patient visited a health care clinic for treatment of upper respiratory tract congestion, fatigue, and sputum production that was rust-colored. Which of the following diagnoses is likely based on this history and inspection of the sputum?
An infection with pneumococcal pneumonia
The nurse is interviewing a patient who says he has a dry, irritating cough that is not "bringing anything up." What medication should the nurse question the patient about taking?
Angiotensin converting enzyme (ACE) inhibitors
The nurse is caring for clients on the neurological unit. Which triad of neurological mechanisms does the nurse identify as most responsible when there is abnormality in ventilation control?
Aortic arch, pons, and CO2 receptor sites
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
A client with newly diagnosed emphysema is admitted to the medical-surgical unit for evaluation. Which does the nurse recognize as a deformity of the chest wall that occurs as a result of overinflation of the lungs in this client population?
Barrel chest
A client presents to the emergency department with fluid overload. The nurse is concerned about fluid accumulation in the lungs. On which of the following areas would the nurse focus the lung assessment?
Bilateral lower lobes Chapter 20: Assessment of Respiratory Function - Page 498 Assessment of the anterior and posterior lungs is part of the nurse's routine evaluation. Fluid overload should be monitored for accumulation in the lungs. Dependent areas must be assessed for breath sounds. The bases of the lungs are considered dependent areas. Fluid in the lungs will usually produce the adventitious sounds of crackles, most frequently auscultated in the bilateral bases of the lungs.
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?
Bronchophony
A client arrives in the emergency department reporting shortness of breath. She has 3+ pitting edema below the knees, a respiratory rate of 36 breaths per minute, and heaving respirations. The nurse auscultates the client's lungs to reveal coarse, moist, high-pitched, and non-continuous sounds that do not clear with coughing. The nurse will document these sounds as which type?
Crackles
The nurse is assessing the lungs of a patient diagnosed with pulmonary edema. Which of the following would be expected upon auscultation?
Crackles at lung bases
A son brings his father into the clinic, stating that his father's color has changed to bluish around the mouth. The father is confused, with a respiratory rate of 28 breaths per minute and scattered crackles throughout. The son states this condition just occurred within the last hour. Which of the following factors indicates that the client's condition has lasted for more than 1 hour?
Cyanosis
Which ventilation-perfusion ratio is exhibited by a pulmonary embolus?
Dead space
Which is an age-related change associated with the respiratory system?
Decreased size of the airway
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?
Diagnosis of peripheral vascular disease
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.
Diaphragm contracts and elongates the chest cavity.
A nurse is obtaining a health history from a client who reports hemoptysis for the past 2 months. The client reports occasional dyspnea. Which imaging study, ordered by the physician, will view the thoracic cavity while in motion?
Fluoroscopy Chapter 20: Assessment of Respiratory Function - Page 504 Fluoroscopy enables the physician to view the thoracic cavity with all of its contents in motion. A fluoroscopy more precisely diagnoses the location of a tumor or lesion. An x-ray shows the size, shape, and position of the lungs. An MRI and CT produce axial views of the lungs.
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?
How these issues affect the client's quality of life Chapter 20: Assessment of Respiratory Function - Page 488 Assessment of the respiratory system includes obtaining information about physical and functional issues related to breathing. It also means clarifying how these issues may affect the client's quality of life. Therefore, options B, C, and D are incorrect.
A client is seen in the emergency room for a case of diabetic acidosis with the presence of Kussmaul respirations. What client condition is associated with the presence of Kussmaul respirations?
Hyperventilation
Bradypnea is associated with which condition?
Increased intracranial pressure
During a pulmonary assessment, the nurse observes the chest for configuration. She identifies the findings as normal. Which of the following would be consistent with normal assessment?
Lateral diameter greater than anteroposterior diameter
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)?
MRI can view soft tissues and can help stage cancers.
Why is it important for a nurse to provide required information and appropriate explanations of diagnostic procedures to patients with respiratory disorders?
Manage decreased energy levels
The nurse is performing an assessment for a patient with congestive heart failure. The nurse asks if the patient has difficulty breathing in any position other than upright. What is the nurse referring to?
Orthopnea
Which term will the nurse use to document the inability of a client to breathe easily unless positioned upright?
Orthopnea
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 Chapter 20: Assessment of Respiratory Function - Page 481-482 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 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?
Pulmonary embolism Chapter 20: Assessment of Respiratory Function - Page 486 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.
The client has just had an invasive procedure to assess the respiratory system. What does the nurse know should be assessed on this client?
Respiratory distress Chapter 20: Assessment of Respiratory Function - Page 500 After invasive procedures, the nurse must carefully check for signs of respiratory distress and blood-streaked sputum. Masses in the pleural space are a condition that affects fremitus. General examination of overall health and condition includes assessing the consciousness of a client.
A nurse is caring for a client after a lung biopsy. Which assessment finding requires immediate intervention?
Respiratory rate of 44 breaths/minute
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?
Rhonchi
Which ventilation-perfusion ratio is exhibited by acute respiratory distress syndrome (ARDS)?
Silent unit Chapter 20: Assessment of Respiratory Function - Page 486 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.
In which position should the client be placed for a thoracentesis?
Sitting on the edge of the bed
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?
Take deep breaths and cough forcefully.
For which reason does gas exchange decrease in older adults?
The alveolar walls contain fewer capillaries.
A client arrives at the physician's office stating 2 days of febrile illness, dyspnea, and cough. Upon assisting the client into a gown, the nurse notes that the client's sternum is depressed, especially on inspiration. Crackles are noted in the bases of the lung fields. Based on inspection, which will the nurse document?
The client has a funnel chest.
Which homeostatic mechanism would the body of a critically ill client use to maintain normal pH?
The lungs eliminate carbonic acid by blowing off more CO2.
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?
They can be heard during inspiration and expiration.
The nurse is studying for a physiology test over the respiratory system. What should the nurse know about central chemoreceptors in the medulla?
They respond to changes in CO2 levels and hydrogen ion concentrations (pH) in the cerebrospinal fluid.
You are studying for a physiology test about the respiratory system. What should you know about central chemoreceptors in the medulla?
They respond to changes in CO2 levels and hydrogen ion concentrations (pH) in the cerebrospinal fluid. Chapter 20: Assessment of Respiratory Function - Page 488 Central chemoreceptors in the medulla respond to changes in CO2 levels and hydrogen ion concentrations (pH) in the cerebrospinal fluid. Central chemoreceptors do not respond to changes in the O2 levels in the brain; changes in CO2 levels in the brain; changes in O2 levels and bicarbonate levels in the atmosphere.
The instructor of the pre-nursing physiology class is explaining respiration to the class. What does the instructor explain is the main function of respiration?
To exchange oxygen and CO2 between the atmospheric air and the blood and between the blood and the cells
A nurse assesses a client's respiratory status. Which observation indicates that the client is having difficulty breathing?
Use of accessory muscles
A client with chronic bronchitis is admitted with an exacerbation of symptoms. During the nursing assessment, the nurse will expect which of the following findings? Select all that apply.
Use of accessory muscles to breathe Purulent sputum with frequent coughing
What is the difference between respiration and ventilation?
Ventilation is the movement of air in and out of the respiratory tract.
The nurse documents breath sounds that are soft, with inspiratory sounds longer than expiratory and found over the periphery of the lungs. Which of the following will the nurse chart?
Vesicular
A patient's lung volumes and capacities were assessed to help determine the cause of a respiratory problem. Which of the following findings are indicative of chronic obstructive pulmonary disease (COPD)?
Vital capacity of 3,000 mL
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?
Wheezes
While auscultating the lungs of a client with asthma, the nurse hears a continuous, high-pitched whistling sound on expiration. The nurse will document this sound as which of the following?
Wheezes
A client is being seen in the pediatric clinic for a middle ear infection. The client's mother reports that when the client develops an upper respiratory infection, an ear infection seems quick to follow. What contributes to this event?
eustachian tubes
A client has been newly diagnosed with emphysema. The nurse should explain to the client that by definition, ventilation:
is breathing air in and out of the lungs.
The volume of air inhaled and exhaled with each breath is termed
tidal volume.
Which hollow tube transports air from the laryngeal pharynx to the bronchi?
trachea
A client will be undergoing a bronchoscopy. Which statement shows that the client understands the procedure?
"It sounds like the different drugs will make this much easier to stand."
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?
Asthma
If concern exists about fluid accumulation in a client's lungs, what area of the lungs will the nurse focus on during assessment?
Bilateral lower lobes
The nurse is performing an assessment of a patient who arrived in the emergency department with a barbiturate overdose. The respirations are normal for 3 to 4 breaths followed by a 60-second period of apnea. How does the nurse document the respirations?
Biot's respirations
A new nurse auscultates adventitious breath sounds but is not sure what to document and confers with an experienced nurse. This experienced nurse documents a pleural friction rub. Which of the following did the experienced nurse do during her assessment to identify the rub?
Instructed the client to hold the breath
A client is receiving moderate sedation while undergoing bronchoscopy. Which assessment finding should the nurse attend to immediately?
Oxygen saturation of 90% Chapter 20: Assessment of Respiratory Function - Page 503 The nurse should respond immediately to an oxygen saturation (SaO2) of 90%. Normal SaO2 ranges from 95% to 100%. Therefore, an SaO2 of 90% indicates inadequate oxygenation, an adverse effect of moderate sedation. The nurse should respond by attempting to arouse the client, assisting the client with deep breathing, and administering a higher dose of oxygen. Cough and gag reflexes are typically absent after administration of anesthetics required for bronchoscopy, and they usually return about 2 hours after the procedure. Blood-tinged secretions are common for several hours after bronchoscopy, especially if a biopsy was obtained. A respiratory rate of 13 breaths/minute is within normal limits.
It is important for the nurse to provide required information and appropriate explanations of diagnostic procedures to clients with respiratory disorders in order to
manage decreased energy levels. Chapter 20: Assessment of Respiratory Function - Page 484 In addition to the nursing management of individual tests, clients with respiratory disorders require informative and appropriate explanations of any diagnostic procedures they will experience. Nurses must remember that for many of these clients, breathing may in some way be compromised and energy levels may be decreased. For that reason, explanations should be brief, yet complete, and may need to be repeated later after a rest period. The nurse must also ensure adequate rest periods before and after the procedures. After invasive procedures, the nurse must carefully assess for signs of respiratory distress.
Pink, frothy sputum may be an indication of
pulmonary edema.
