Ch.20: Assessment of Respiratory Function

Which of the following is a late sign of hypoxia?

Cyanosis

A nurse assesses a client's respiratory status. Which observation indicates that the client is having difficulty breathing?

Use of accessory muscles

Knowing respiratory physiology is important to understand how the disease process can work within that system. Which hollow tube transports air from the laryngeal pharynx to the bronchi?

Trachea

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."

What is the difference between respiration and ventilation?

Ventilation is the movement of air in and out of the respiratory tract

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

Clubbing of the fingers

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

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. Included in teaching would be which of the following regarding the MRI?

MRI can view soft tissues and can help stage cancers

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

Pink frothy sputum may be an indication of:

pulmonary edema

The term for the volume of air inhaled and exhaled with each breath is:

tidal volume

The nurse is instructing the client on the normal sensations, which can occur when contrast medium is infused during pulmonary angiography. Which statement, made by the client, demonstrates an understanding?

"I will feel warm and an urge to cough."

A nurse would question the accuracy of a pulse oximetry evaluation in which of the following conditions?

A client experiencing hypothermia

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

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

Which of the following terms will the nurse use to document the inability of a patient to breathe easily unless positioned upright?

Orthopnea

The nurse is caring for a client with chronic obstructive pulmonary disease. The client calls the doctor and states having difficulty breathing and overall feeling fatigued. The nurse realizes that this client is at high risk for which condition?

Respiratory acidosis

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 caring for a patient diagnosed with pneumonia. The nurse will assess the patient for tactile fremitus by completing which of the following?

Asking the patient to repeat "ninety-nine" as the nurse's hands move down the patient's thorax

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

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

The nurse is assessing a patient in respiratory failure. What finding is a late indicator of hypoxia?

Cyanosis

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

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

No sensation during palpation

When assessing a client, which adaptation indicates the presence of respiratory distress?

Orthopnea

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

A nurse is reviewing arterial blood gas results on an assigned client. The pH is 7.32 with PCO2 of 49 mm Hg and a HCO3−of 28 mEq/L. The nurse reports to the physician which finding?

Respiratory acidosis

A client with chronic bronchitis is admitted to the health facility. Auscultation of the lungs reveals low-pitched, rumbling sounds. Which of the following describes these sounds?

Rhonchi

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

Sitting on the edge of the bed

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

Swallow reflex

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

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%

A 53-year-old male is a regular client in the respiratory group where you practice nursing. As with all adults, millions of alveoli form most of the pulmonary mass. The squamous epithelial cells lining each alveolus consist of different types of cells. Which type of the alveoli cells produce surfactant?

Type II cells

The nurse is instructing the patient on the collection of a sputum specimen. What should be included in the instructions? (Select all that apply.)

-Initially, clear the nose and throat. -Take a few deep breaths before coughing. -Use diaphragmatic contractions to aid in the expulsion of sputum.

The nurse working in the radiology clinic is assisting with a pulmonary angiography. The nurse knows that when monitoring clients after a pulmonary angiography, what should the physician be notified about?

Absent distal pulses

The nurse is caring for a patient with recurrent hemoptysis who has undergone a bronchoscopy. Immediately following the procedure, the nurse should complete which of the following?

Assess the patient for a cough reflex

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

Which of the following is a deformity of the chest that occurs as a result of over inflation of the lungs?

Barrel chest

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

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

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

During a preadmission assessment, for what diagnosis would the nurse expect to find decreased tactile fremitus and hyperresonant percussion sounds?

Emphysema

A patient with sinus congestion complains of discomfort when the nurse is palpating the supraorbital ridges. The nurse knows that the patient is referring to which sinus?

Frontal

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

A 53-year-old client sees the physician because he has had laryngitis for 2 weeks. After a thorough examination, the doctor orders medications and instructs the client to follow-up in 1 week if his voice has not improved. What is the primary function of the larynx?

Producing sound

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 patient who is to undergo a thoracentesis. In preparation for the procedure, the nurse will position the patient in which of the following positions?

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

The nurse answers the call light of a male patient. The patient is complaining of 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 which of the following?

The lungs

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

A client with a suspected pulmonary disorder undergoes pulmonary function tests. To interpret test results accurately, the nurse must be familiar with the terminology used to describe pulmonary functions. Which term refers to the volume of air inhaled or exhaled during each respiratory cycle?

Tidal volume

The nursing instructor is teaching a pre-nursing pathophysiology class. The class is covering the respiratory system. The instructor explains that the respiratory system is comprised of both the upper and lower respiratory system. The nose is part of the upper respiratory system. The instructor continues to explain that the nasal cavities have a vascular and ciliated mucous lining. What is the purpose of the vascular and ciliated mucous lining of the nasal cavities?

Warm and humidify inspired air

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

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

The amount of air inspired and expired with each breath is called:

tidal volume.