Chap 20-Assessment of Respiratory Function

The clinic nurse is caring for a patient who has been diagnosed with emphysema and who has just had a pulmonary function test (PFT) ordered. The patient asks, What exactly is this test for? What would be the nurses best response? A) A PFT measures how much air moves in and out of your lungs when you breathe. B) A PFT measures how much energy you get from the oxygen you breathe. C) A PFT measures how elastic your lungs are. D) A PFT measures whether oxygen and carbon dioxide move between your lungs and your blood.

A) A PFT measures how much air moves in and out of your lungs when you breathe.

The nurse has assessed a patients family history for three generations. The presence of which respiratory disease would justify this type of assessment? A) Asthma B) Obstructive sleep apnea C) Community-acquired pneumonia D) Pulmonary edema

A) Asthma

The medical nurse who works on a pulmonology unit is aware that several respiratory conditions can affect lung tissue compliance. The presence of what condition would lead to an increase in lung compliance? A) Emphysema B) Pulmonary fibrosis C) Pleural effusion D) Acute respiratory distress syndrome (ARDS)

A) Emphysema

The nurse is caring for a patient with a lower respiratory tract infection. When planning a focused respiratory assessment, the nurse should know that this type of infection most often causes what? A) Impaired gas exchange B) Collapsed bronchial structures C) Necrosis of the alveoli D) Closed bronchial tree

A) Impaired gas exchange

A patient on the medical unit has told the nurse that he is experiencing significant dyspnea, despite that he has not recently performed any physical activity. What assessment question should the nurse ask the patient while preparing to perform a physical assessment? A) On a scale from 1 to 10, how bad would rate your shortness of breath? B) When was the last time you ate or drank anything? C) Are you feeling any nausea along with your shortness of breath? D) Do you think that some medication might help you catch your breath?

A) On a scale from 1 to 10, how bad would rate your shortness of breath?

The nurse is caring for a patient who has returned to the unit following a bronchoscopy. The patient is asking for something to drink. Which criterion will determine when the nurse should allow the patient to drink fluids? A) Presence of a cough and gag reflex B) Absence of nausea C) Ability to demonstrate deep inspiration D) Oxygen saturation of 92%

A) Presence of a cough and gag reflex

The ED nurse is assessing a patient complaining of dyspnea. The nurse auscultates the patients chest and hears wheezing throughout the lung fields. What might this indicate? A) The patient has a narrowed airway. B) The patient has pneumonia. C) The patient needs physiotherapy. D) The patient has a hemothorax.

A) The patient has a narrowed airway.

A nurse educator is reviewing the implications of the oxyhemoglobin dissociation curve with regard to the case of a current patient. The patient currently has normal hemoglobin levels, but significantly decreased SaO2 and PaO2 levels. What is an implication of this physiological state? A) The patients tissue demands may be met, but she will be unable to respond to physiological stressors. B) The patients short-term oxygen needs will be met, but she will be unable to expel sufficient CO2. C) The patient will experience tissue hypoxia with no sensation of shortness of breath or labored breathing. D) The patient will experience respiratory alkalosis with no ability to compensate.

A) The patients tissue demands may be met, but she will be unable to respond to physiological stressors.

The nurse is performing a respiratory assessment of an adult patient and is attempting to distinguish between vesicular, bronchovesicular, and bronchial (tubular) breath sounds. The nurse should distinguish between these normal breath sounds on what basis? A) Their location over a specific area of the lung B) The volume of the sounds C) Whether they are heard on inspiration or expiration D) Whether or not they are continuous breath sounds

A) Their location over a specific area of the lung

The nurse is assessing a newly admitted medical patient and notes there is a depression in the lower portion of the patients sternum. This patients health record should note the presence of what chest deformity? A) A barrel chest B) A funnel chest C) A pigeon chest D) Kyphoscoliosis

B) A funnel chest

The nurse is performing a respiratory assessment of a patient who has been experiencing episodes of hypoxia. The nurse is aware that this is ultimately attributable to impaired gas exchange. On what factor does adequate gas exchange primarily depend? A) An appropriate perfusiondiffusion ratio B) An adequate ventilationperfusion ratio C) Adequate diffusion of gas in shunted blood D) Appropriate blood nitrogen concentration

B) An adequate ventilationperfusion ratio

A gerontologic nurse is analyzing the data from a patients focused respiratory assessment. The nurse is aware that the amount of respiratory dead space increases with age. What is the effect of this physiological change? A) Increased diffusion of gases B) Decreased diffusion capacity for oxygen C) Decreased shunting of blood D) Increased ventilation

B) Decreased diffusion capacity for oxygen

The nurse doing rounds at the beginning of a shift notices a sputum specimen in a container sitting on the bedside table in a patients room. The nurse asks the patient when he produced the sputum specimen and he states that the specimen is about 4 hours old. What action should the nurse take? A) Immediately take the sputum specimen to the laboratory. B) Discard the specimen and assist the patient in obtaining another specimen. C) Refrigerate the sputum specimen and submit it once it is chilled. D) Add a small amount of normal saline to moisten the specimen.

B) Discard the specimen and assist the patient in obtaining another specimen.

While assessing a patient who has pneumonia, the nurse has the patient repeat the letter E while the nurses auscultates. The nurse notes that the patients voice sounds are distorted and that the letter A is audible instead of the letter E. How should this finding be documented? A) Bronchophony B) Egophony C) Whispered pectoriloquy D) Sonorous wheezes

B) Egophony

A sputum study has been ordered for a patient who has developed coarse chest crackles and a fever. At what time should the nurse best collect the sample? A) Immediately after a meal B) First thing in the morning C) At bedtime D) After a period of exercise

B) First thing in the morning

The nurse is caring for a patient with lung metastases who just underwent a mediastinotomy. What should be the focus of the nurses postprocedure care? A) Assisting with pulmonary function testing (PFT) B) Maintaining the patients chest tube C) Administering oral suction as needed D) Performing chest physiotherapy

B) Maintaining the patients chest tube

The nurse is assessing a patient who frequently coughs after eating or drinking. How should the nurse best follow up this assessment finding? A) Obtain a sputum sample. B) Perform a swallowing assessment. C) Inspect the patients tongue and mouth. D) Assess the patients nutritional status.

B) Perform a swallowing assessment.

A patient has been diagnosed with pulmonary hypertension, in which the capillaries in the alveoli are squeezed excessively. The nurse should recognize a disturbance in what aspect of normal respiratory function? A) Acidbase balance B) Perfusion C) Diffusion D) Ventilation

B) Perfusion

The nurse is caring for a patient 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? A) Sputum production B) Shortness of breath C) Throat discomfort D) Epistaxis

B) Shortness of breath

A patient is having her tonsils removed. The patient asks the nurse what function the tonsils normally serve. Which of the following would be the most accurate response? A) The tonsils separate your windpipe from your throat when you swallow. B) The tonsils help to guard the body from invasion of organisms. C) The tonsils make enzymes that you swallow and which aid with digestion. D) The tonsils help with regulating the airflow down into your lungs

B) The tonsils help to guard the body from invasion of organisms.

A medical patient rings her call bell and expresses alarm to the nurse, stating, Ive just coughed up this blood. That cant be good, can it? How can the nurse best determine whether the source of the blood was the patients lungs? A) Obtain a sample and test the pH of the blood, if possible. B) Try to see if the blood is frothy or mixed with mucus. C) Perform oral suctioning to see if blood is obtained. D) Swab the back of the patients throat to see if blood is present.

B) Try to see if the blood is frothy or mixed with mucus.

A patient with a decreased level of consciousness is in a recumbent position. How should the nurse best assess the lung fields for a patient in this position? A) Inform that physician that the patient is in a recumbent position and anticipate an order for a portable chest x-ray. B) Turn the patient to enable assessment of all the patients lung fields. C) Avoid turning the patient, and assess the accessible breath sounds from the anterior chest wall. D) Obtain a pulse oximetry reading, and, if the reading is low, reposition the patient and auscultate breath sounds.

B) Turn the patient to enable assessment of all the patients lung fields.

The nurse is caring for a patient admitted with an acute exacerbation of chronic obstructive pulmonary disease. During assessment, the nurse finds that the patient is experiencing increased dyspnea. What is the most accurate measurement of the concentration of oxygen in the patients blood? A) A capillary blood sample B) Pulse oximetry C) An arterial blood gas (ABG) study D) A complete blood count (CBC)

C) An arterial blood gas (ABG) study

The ED nurse is assessing the respiratory function of a teenage girl who presented with acute shortness of breath. Auscultation reveals continuous wheezes during inspiration and expiration. This finding is most suggestive what? A) Pleurisy B) Emphysema C) Asthma D) Pneumonia

C) Asthma

While assessing an acutely ill patients respiratory rate, the nurse assesses four normal breaths followed by an episode of apnea lasting 20 seconds. How should the nurse document this finding? A) Eupnea B) Apnea C) Biots respiration D) Cheyne-Stokes

C) Biots respiration

The nurse is caring for an elderly patient in the PACU. The patient has had a bronchoscopy, and the nurse is monitoring for complications related to the administration of lidocaine. For what complication related to the administration of large doses of lidocaine in the elderly should the nurse assess? A) Decreased urine output and hypertension B) Headache and vision changes C) Confusion and lethargy D) Jaundice and elevated liver enzymes

C) Confusion and lethargy

The nurse is completing a patients health history with regard to potential risk factors for lung disease. What interview question addresses the most significant risk factor for respiratory diseases? A) Have you ever been employed in a factory, smelter, or mill? B) Does anyone in your family have any form of lung disease? C) Do you currently smoke, or have you ever smoked? D) Have you ever lived in an area that has high levels of air pollution?

C) Do you currently smoke, or have you ever smoked?

The nurse is assessing the respiratory status of a patient who is experiencing an exacerbation of her emphysema symptoms. When preparing to auscultate, what breath sounds should the nurse anticipate? A) Absence of breath sounds B) Wheezing with discontinuous breath sounds C) Faint breath sounds with prolonged expiration D) Faint breath sounds with fine crackles

C) Faint breath sounds with prolonged expiration

A medical nurse has admitted a patient to the unit with a diagnosis of failure to thrive. The patient has developed a fever and cough, so a sputum specimen has been obtained. The nurse notes that the sputum is greenish and that there is a large quantity of it. The nurse notifies the patients physician because these symptoms are suggestive of what? A) Pneumothorax B) Lung tumors C) Infection D) Pulmonary edema

C) Infection

A patient is undergoing testing to see if he has a pleural effusion. Which of the nurses respiratory assessment findings would be most consistent with this diagnosis? A) Increased tactile fremitus, egophony, and a dull sound upon percussion of the chest wall B) Decreased tactile fremitus, wheezing, and a hyperresonant sound upon percussion of the chest wall C) Lung fields dull to percussion, absent breath sounds, and a pleural friction rub D) Normal tactile fremitus, decreased breath sounds, and a resonant sound upon percussion of the chest wall

C) Lung fields dull to percussion, absent breath sounds, and a pleural friction rub

A patient asks the nurse why an infection in his upper respiratory system is affecting the clarity of his speech. Which structure serves as the patients resonating chamber in speech? A) Trachea B) Pharynx C) Paranasal sinuses D) Larynx

C) Paranasal sinuses

A patient with chronic lung disease is undergoing lung function testing. What test result denotes the volume of air inspired and expired with a normal breath? A) Total lung capacity B) Forced vital capacity C) Tidal volume D) Residual volume

C) Tidal volume

A patient is being treated for a pulmonary embolism and the medical nurse is aware that the patient suffered an acute disturbance in pulmonary perfusion. This involved an alteration in what aspect of normal physiology? A) Maintenance of constant osmotic pressure in the alveoli B) Maintenance of muscle tone in the diaphragm C) pH balance in the pulmonary veins and arteries D) Adequate flow of blood through the pulmonary circulation.

D) Adequate flow of blood through the pulmonary circulation.

The patient has just had an MRI ordered because a routine chest x-ray showed suspicious areas in the right lung. The physician suspects bronchogenic carcinoma. An MRI would most likely be order to assess for what in this patient? A) Alveolar dysfunction B) Forced vital capacity C) Tidal volume D) Chest wall invasion

D) Chest wall invasion

A patient has been diagnosed with heart failure that has not yet responded to treatment. What breath sound should the nurse expect to assess on auscultation? A) Expiratory wheezes B) Inspiratory wheezes C) Rhonchi D) Crackles

D) Crackles

A patient is scheduled to have excess pleural fluid aspirated with a needle in order to relieve her dyspnea. The patient inquires about the normal function of pleural fluid. What should the nurse describe? A) It allows for full expansion of the lungs within the thoracic cavity. B) It prevents the lungs from collapsing within the thoracic cavity. C) It limits lung expansion within the thoracic cavity. D) It lubricates the movement of the thorax and lungs.

D) It lubricates the movement of the thorax and lungs.

In addition to heart rate, blood pressure, respiratory rate, and temperature, the nurse needs to assess a patients arterial oxygen saturation (SaO2). What procedure will best accomplish this? A) Incentive spirometry B) Arterial blood gas (ABG) measurement C) Peak flow measurement D) Pulse oximetry

D) Pulse oximetry

The nurse is caring for a patient who has just returned to the unit after a colon resection. The patient is showing signs of hypoxia. The nurse knows that this is probably caused by what? A) Nitrogen narcosis B) Infection C) Impaired diffusion D) Shunting

D) Shunting

A patient has a diagnosis of multiple sclerosis. The nurse is aware that neuromuscular disorders such as multiple sclerosis may lead to a decreased vital capacity. What does vital capacity measure? A) The volume of air inhaled and exhaled with each breath B) The volume of air in the lungs after a maximal inspiration C) The maximal volume of air inhaled after normal expiration D) The maximal volume of air exhaled from the point of maximal inspiration

D) The maximal volume of air exhaled from the point of maximal inspiration

The nurse is caring for a patient who has been scheduled for a bronchoscopy. How should the nurse prepare the patient for this procedure? A) Administer a bolus of IV fluids. B) Arrange for the insertion of a peripherally inserted central catheter. C) Administer nebulized bronchodilators every 2 hours until the test. D) Withhold food and fluids for several hours before the test.

D) Withhold food and fluids for several hours before the test.