Chapter 20: Assessment of Respiratory Function (1)
A nurse would question the accuracy of a pulse oximetry evaluation in which of the following conditions? pg. 503
A client experiencing hypothermia
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? pg. 498
Bilateral lower lobes
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? pg. 511
Blood gases
What finding by the nurse may indicate that the client has chronic hypoxia? pg. 492
Clubbing of the fingers
A nurse is preparing a client for bronchoscopy. Which instruction should the nurse give to the client? pg. 506
Do not eat or drink for 6 hours before the procedure.
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? pg. 488
How these issues affect the client's quality of life
What would the instructor tell the students purulent fluid indicates? pg. 507
Infection
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.
When assessing a client, which adaptation indicates the presence of respiratory distress? pg. 489
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? pg. 490
Pleurisy
A patient describes his chest pain as knife-like on inspiration. Which of the following is the most likely diagnosis? pg. 490
Pleurisy
What is the primary function of the larynx? pg. 481
Producing sound
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 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? pg. 488
The pons
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.
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? pg. 483-484
To exchange oxygen and CO2 between the atmospheric air and the blood and between the blood and the 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? pg. 483
Type II cells
A nurse is preparing a client with a pleural effusion for a thoracentesis. The nurse should: pg. 507
assist the client to a sitting position on the edge of the bed, leaning over the bedside table.
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 pg. 490
lungs.
The term for the volume of air inhaled and exhaled with each breath is pg. 501
tidal volume.
