Chapter 20: Assessment of Respiratory Function (2)
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 pg. 492
22.
A nurse would question the accuracy of a pulse oximetry evaluation in which of the following conditions? pg. 503
A client experiencing hypothermia
What finding by the nurse may indicate that the client has chronic hypoxia? pg. 492
Clubbing of the fingers
A client appears to be breathing faster than during the last assessment. Which of the following actions should the nurse perform? pg. 495
Count the rate of respirations.
The nurse is assessing a patient in respiratory failure. What finding is a late indicator of hypoxia? pg. 492
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? pg. 503
Diagnosis of peripheral vascular disease
What would the instructor tell the students purulent fluid indicates? pg. 507
Infection
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.
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? pg. 506
The nursing assistant is pouring a glass of water to wet the client's mouth.
What is the purpose of the vascular and ciliated mucous lining of the nasal cavities? pg. 481
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? pg. 505
Absent distal pulses
The nurse is caring for a client diagnosed with pneumonia. The nurse assesses the client for tactile fremitus by completing which action? pg. 496-497
Asking the client to repeat "ninety-nine" as the nurse's hands move down the client's thorax
The nurse is assessing the lungs of a patient diagnosed with pulmonary edema. Which of the following would be expected upon auscultation? pg. 500
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? pg. 492
Cyanosis
Which of the following clinical manifestations should a nurse monitor for during a pulmonary angiography, which indicates an allergic reaction to the contrast medium? pg. 504
Difficulty in breathing
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.
What is the primary function of the larynx? pg. 481
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? pg. 503
Pulse oximetry
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? pg. 503
Take deep breaths and cough forcefully.
Perfusion refers to blood supply to the lungs, through which the lungs receive nutrients and oxygen. What are the two methods of perfusion? pg. 484
The two methods of perfusion are the bronchial and pulmonary circulation.
