Gas Exchange PrepU (Respiratory Assessment)

Which of the following alveolar cells secrete surfactant? Type II Type I Type III Type IV

Type II

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. 11. 10. 5.

22

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? 40% 75% 80% 95%

95%

What finding by the nurse may indicate that the patient has chronic hypoxia? Crackles Peripheral edema Clubbing of the fingers Cyanosis

Clubbing of the fingers --- is a change in the normal nail bed. It appears as sponginess of the nail bed and loss of the nail bed angle (Fig. 20-6). It is a sign of lung disease that is found in patients with chronic hypoxic conditions, chronic lung infections, or malignancies of the lung

A client appears to be breathing faster than during the last assessment. Which of the following interventions should the nurse perform? Inquire if there have been any stressful visitors. Assist the client to lie down. Count the rate of respirations. Assess the radial pulse.

Count the rate of respirations.

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 Dyspnea Restlessness Confusion

Cyanosis ---Cyanosis, a bluish coloring of the skin, is a very late indicator of hypoxia. The presence or absence of cyanosis is determined by the amount of unoxygenated hemoglobin in the blood. Cyanosis appears when there is at least 5 g/dL of unoxygenated hemoglobin.

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? PaO2 PaCO2 pH SaO2

PaCO2 ---When the minute ventilation falls, alveolar ventilation in the lungs also decreases, and the PaCO2 increases.

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: lips. mucous membranes. nail beds. earlobes.

mucous membranes

A nurse would question the accuracy of a pulse oximetry evaluation in which of the following conditions? A client receiving oxygen therapy via Venturi mask A client experiencing hypothermia A client sitting in a chair after prolonged bed rest A client on a ventilator with PEEP

A client experiencing hypothermia ---SpO2 values obtained by pulse oximetry are unreliable in states of low perfusion such as hypothermia.

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: ---Posterior surface of the left side of the chest, near the sixth rib. --- Anterior surface of the right side of the chest, between the fourth and fifth rib. --- Posterior surface of the right side of the chest, near T3. --- Anterior surface of the left side of the chest, near the sixth rib

Anterior surface of the right side of the chest, between the fourth and fifth rib. ---The middle lobe of the lung is only found on the right side of the thorax and can only be assessed anteriorly. It is located at the fourth rib, at the right sternal border and extends to the fifth rib, in the midaxillary line.

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? Wheezes Rhonchi Crackles Pleural rub

Crackles ---Crackles are adventitious breath sounds that are high-pitched, discontinuous, and popping; they may or may not clear with coughing and are moist. Often crackles are associated with heart failure.

The nurse working on a gerontology unit admits a 77-year-old with recent shortness of breath. The nurse knows that the amount of respiratory dead space increases with age. What do these changes result in? Increased diffusion of gases Decreased diffusion capacity for oxygen Decreased shunting of blood Increased ventilation

Decreased diffusion capacity for oxygen ---The amount of respiratory dead space increases with age. These changes result in a decreased diffusion capacity for oxygen with increasing age, producing lower oxygen levels in the arterial circulation. Shunting does not typically decrease and ventilation does not increase.

What is the purpose of the vascular and ciliated mucous lining of the nasal cavities? Cool and dry expired air Move mucus to the back of the throat Moisten and filter expired air Warm and humidify inspired air

Warm and humidify inspired air

Which term is used to describe the inability to breathe easily except in an upright position? Orthopnea Dyspnea Hemoptysis Hypoxemia

orthopnea

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? --"My study is scheduled for 10 AM, several hours after I eat." -- "I brought comfortable clothes and shoes for the test." --"I am ordered a bronchodilator to note lung improvement following use." -- "I will breathe in through my mouth and out through my nose."

"I will breathe in through my mouth and out through my nose." ---The nurse would clarify the client's statement of improper breathing technique. During a pulmonary function test using a spirometer, a nose clip prevents air from escaping through the client's nose when blowing into the spirometer. All other statements are correct.

Following a chest X-ray, a patient has been diagnosed with a pleural effusion. The care team has concluded that the quantity of fluid in the patient's intrapleural space necessitates thoracentesis. What patient education should the nurse provide in anticipation of this procedure? --"You can move around as normal after the procedure is finished, and I've applied a bandage over the site." --"The doctor will ask you to cough a few times to facilitate the insertion of the needle." --"If you're unable to lie on your side, you can sit upright and support yourself on your overbed table." --"It's very important that you remain still while the doctor is performing the procedure."

"It's very important that you remain still while the doctor is performing the procedure."

The student nurse is caring for a client who has serial sputum tests ordered. The student asks the instructor why the sputum tests have to be repeated on successive days. What would be the instructor's best response? --"Some clients cannot produce enough sputum to be tested, so successive samples may be needed." -- "The sputum produced today may be from the left lung and tomorrow it may be from the right lung." -- "Sometimes two tests are needed to verify a positive finding." -- "A negative sputum test does not always mean that there is no disease present, so more than one test may be needed."

A negative sputum test does not always mean that there is no disease present, so more than one test may be needed

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 trachea and bronchi The pleural surfaces A catheter in the arm vein

A puncture at the radial artery

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? Raised temperature in the affected limb Excessive capillary refill Absent distal pulses Flushed feeling in the client

Absent distal pulses ----When monitoring clients after a pulmonary angiography, nurses must notify the physician 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.

Which is a true statement regarding air pressure variances? --Air is drawn through the trachea and bronchi into the alveoli during inspiration. -- Air flows from a region of lower pressure to a region of higher pressure during inspiration. -- The diaphragm contracts during inspiration. -- The thoracic cavity becomes smaller during inspiration.

Air is drawn through the trachea and bronchi into the alveoli during inspiration ---Air flows from a region of higher pressure to a region of lower pressure. During inspiration, movement of the diaphragm and other muscles of respiration enlarge the thoracic cavity, thereby lowering the pressure inside the thorax to a level below that of atmospheric pressure.

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? Bronchiectasis An infection with pneumococcal pneumonia A lung abscess Bronchitis

An infection with pneumococcal pneumonia -----Sputum that is rust colored suggests infection with pneumococcal pneumonia. Bronchiectasis and a lung abscess usually are associated with purulent thick and yellow-green sputum. Bronchitis usually yields a small amount of purulent sputum.

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 Aspirin Bronchodilators Cardiac glycosides

Angiotensin converting enzyme (ACE) inhibitors

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? Ensure the client remains moderately sedated to decrease anxiety. Offer the client ice chips. Assess the client for a cough reflex. Instruct the client that bed rest must be maintained for 2 hours.

Assess the client for cough reflex ---After the procedure, the client must take nothing by mouth until the cough reflex returns, because the preoperative sedation and local anesthesia impair the protective laryngeal reflex and swallowing. Once the client demonstrates a cough reflex, the nurse may offer ice chips and eventually fluids. The client is sedated during the procedure, not afterward. The client is not required to maintain bed rest following the procedure.

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? Acute respiratory obstruction Adult respiratory distress syndrome Pneumothorax Asthma

Asthma ---The presence of both inspiratory and expiratory wheezing usually signifies asthma if the individual does not have heart failure. Sudden dyspnea is an indicator of the other choices.

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? Funnel chest Pigeon chest Barrel chest Kyphoscoliosis

Barrel chest---A barrel chest occurs as a result of over inflation of the lungs. The anteroposterior diameter of the thorax increases. Barrel chest occurs with aging and is a hallmark sign of emphysema and chronic obstructive pulmonary disease (COPD). In a client with emphysema, the ribs are more widely spaced and the intercostal spaces tend to bulge upon expiration. Funnel chest occurs when a depression occurs in the lower portion of the sternum, which may result in murmurs. Pigeon chest occurs as a result of displacement of the sternum, resulting in an increase in the anteroposterior diameter. Kyphoscoliosis is characterized by elevation of the scapula and a corresponding S-shaped spine. This deformity limits lung expansion within the thorax.

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? Right lower lobe Posterior bronchioles Bilateral lower lobes Anterior bronchial tree

Bilateral lower lobe Assessment of the anterior and posterior lungs is part of the nurse's routine evaluation. Fluid overload should be monitored for accumluation 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 lung

In a patient diagnosed with increased intracranial pressure (IICP), the nurse would expect to observe which of the following respiratory rate or depth? Bradypnea Tachypnea Hypoventilation Hyperventilation

Bradypnea ---Bradypnea is a slower than normal rate (<10 breaths/minute), with normal depth and regular rhythm. It is associated with IICP, brain injury, central nervous system depressants, and drug overdose. Tachypnea is associated with metabolic acidosis, septicemia, severe pain, and rib fracture. Hypoventilation is shallow, irregular breathing. Hyperventilation is an increased rate and depth of breathing.

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? Placement of the probe on an earlobe Diagnosis of peripheral vascular disease Reduced lighting in the room Increased temperature of the room

Diagnosis of peripheral vascular disease ---Inaccuracy of results may be from anemia, bright lights, shivering, nail polish, or 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. --Lungs are pulled up and pushed back against the thoracic cage. -- Diaphragm contracts and elongates the chest cavity. --Intercostals muscles relax to allow for expansion. --Anteroposterior rib diameter decreases.

Diaphragm contracts and elongates the chest cavity

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 Hematoma Absent distal pulses Urge to cough

Difficulty in breathing ---Nurses must determine if the client has any allergies, particularly to iodine, shellfish, or contrast dye. During the procedure, the nurse should check for signs and symptoms of allergic reactions to the contrast medium, such as itching, hives, or difficulty in breathing. The nurses inspects for hematoma, absent distal pulses, after the procedure. When the contrast medium is infused, an urge to cough is often a sensation experienced by the client.

A nurse is preparing a client for bronchoscopy. Which instruction should the nurse give to the client? Don't walk. Don't cough. Don't talk. Don't eat.

Don't eat ---Bronchoscopy involves visualization of the trachea and bronchial tree. To prevent aspiration of stomach contents into the lungs, the nurse should instruct the client not to eat or drink anything for approximately 6 hours before the procedure. It isn't necessary for the client to avoid walking, talking, or coughing.

Lung compliance (the ability of the lungs to stretch) is a physical factor that affects ventilation. A nurse is aware that a patient who has lost elasticity in the lung tissue has a condition known as: Atelectasis Pulmonary edema Emphysema Pleural effusion

Emphysema

A 68-year-old male patient has been admitted to the surgical unit from the PACU after surgical repair of an inguinal hernia. When performing the patient's admission assessment, the nurse notes that the patient has a barrel chest. This assessment finding should suggest to the nurse that the patient may have a history of what health problem? Asthma Emphysema Tuberculosis Chronic bronchitis

Emphysema ---Barrel chest occurs as a result of lung hyperinflation, as in emphysema. There is an increase in the anteroposterior diameter of the thorax so that it approximates a 1:1 ratio.

High or increased compliance occurs in which disease process? Emphysema Pneumothorax Pleural effusion ARDS

Emphysema ---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). Reference:

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 Chest x-ray Magnetic resonance imaging (MRI) Computed tomography (CT) scan

Fluoroscopy

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 Ethmoidal Maxillary Sphenoidal

Frontal

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. The client has chronic respiratory disease. The client has pneumonia in the bases. The client needs a cough suppressant.

Funnel chest ----The question asks for a documentation based on inspection. A funnel chest, known as pectus excavatum, has the sternum depressed from the second intercostal space, and it is more pronounced on inspiration.

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 a dull pain when the catheter is introduced." -- "I will feel light-headed when the contrast medium is introduced." -- "I will feel waves of nausea throughout the procedure." --"I will feel warm and an urge to cough."

I will feel warm and an urge to cough.

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? Acute Pain Potential for Infection Impaired Gas Exchange Ineffective Airway Clearance

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? Ineffective airway clearance Impaired gas exchange Decreased cardiac output Impaired spontaneous ventilation

Impaired gas exchange ---

You are performing pulmonary function studies on clients in the clinic. What position do you know a client should be in to have maximum lung capacities and volumes? Lying on the unaffected side Resting the head on a pillow Lying flat on the back In the standing position

In the standing position

The nursing instructor is talking with senior nursing students about diagnostic procedures used in respiratory diseases. The instructor discusses thoracentesis, defining it as a procedure performed for diagnostic purposes or to aspirate accumulated excess fluid or air from the pleural space. What would the instructor tell the students purulent fluid indicates? Cancer Infection Inflammation Heart failure

Infection

Which respiratory volume is the maximum volume of air that can be inhaled after maximal expiration? Tidal volume Expiratory reserve volume Residual volume Inspiratory reserve volume

Inspiratory reserve volume ---Inspiratory reserve volume is normally 3000 mL. Tidal volume is the volume of air inhaled and exhaled with each breath. Expiratory reserve volume is the maximum volume of air that can be exhaled forcibly after a normal exhalation. Residual volume is the volume of air remaining in the lungs after a maximum exhalation.

A patient diagnosed with diabetic ketoacidosis would be expected to have which type of respiratory pattern? Kussmaul respirations Cheyne-Stokes Biot's respirations Apnea

Kussmaul respirations ---Kussmaul respirations are seen in patients with diabetic ketoacidosis. In Cheyne-Stokes respiration, rate and depth increase, then decrease until apnea occurs. Biot's respiration is characterized by periods of normal breathing (3 to 4 breaths) followed by a varying period of apnea (usually 10 to 60 seconds)

A client has just undergone bronchoscopy. Which nursing assessment is most important at this time? Level of consciousness (LOC) Memory Personality changes Intellectual ability

Level of consciousness (LOC) ---Following bronchoscopy, LOC is the most important assessment because changes in the client's LOC may alert the nurse to serious neurologic problems. Memory, personality changes, and intellectual ability are important but don't take precedence at this time.

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. stomach. nose. rectum.

Lungs ---Blood from the lung is usually bright red, frothy, and mixed with sputum. Initial symptoms include a tickling sensation in the throat, a salty taste, a burning or bubbling sensation in the chest, and perhaps chest pain, in which case the client tends to splint the bleeding side. This blood has an alkaline pH (>7.0). Blood from the stomach is vomited rather than expectorated, may be mixed with food, and is usually much darker; it is often referred to as "coffee ground emesis." This blood has an acidic pH (<<7.0). Bloody sputum from the nose or the nasopharynx is usually preceded by considerable sniffing, with blood possibly appearing in the nose.

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? Client can perform incentive spirometry. Lungs are clear on auscultation. Respiratory rate is 12 to 18 breaths per minute. Client reports no chest pain.

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? In the supine position Lying on the unaffected side In the high Fowler's position Prone with a pillow under the head

Lying on the unaffected side ---Following a thoracentesis, the client remains on bed rest and typically lies on the unaffected side for at least 1 hour to promote expansion of the lung on the affected side. Lying flat in a supine position or prone does not promote expansion of the lung.

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? -Tumor densities can be seen with radiolucent images. --Narrow-beam x-ray can scan successive lung layers. ----Lung blood flow can be viewed after a radiopaque agent is injected. -MRI can view soft tissues and can help stage cancers.

MRI can view soft tissues and can help stage cancers. ---MRI uses magnetic fields and radiofrequency signals to produce a detailed diagnostic image. MRI can visualize soft tissues, characterize nodules, and help stage carcinomas. The other options describe different studies.

Upon palpation of the sinus area, what would the nurse identify as a normal finding? Light not going through the sinus cavity Pain sensation behind the eyes Tenderness during palpation No sensation during palpation

No sensation during palpation ---Sinus assessment involves using the thumbs to apply gentle pressure in an upward fashion at the sinuses. Tenderness suggests inflammation. The sinuses can be inspected by transillumination, where a light is passed through the sinuses. If the light fails to penetrate, the cavity contains fluid.

A nurse practitioner diagnosed a patient with an infection in the maxillary sinuses. Select the area that the nurse palpated to make that diagnosis. Above the eyebrows Between the eyes and behind the nose On the cheeks below the eyes Behind the ethmoid sinuses

On the cheeks below the eyes

The nurse is caring for a client with hypoxemia of unknown cause. Which of the following oxygen transport considerations does the nurse identify as crucial to circulate oxygen in the body system? Select all that apply. --Oxygen is dissolved. --High blood pressure disrupts oxygen transport. --Oxyhemoglobin circulates to the body tissue. --All systemic oxygen is available for diffusion. --Adequate red blood cells are needed for oxygen transport.

Oxygen is dissolved Adequate red blood cells are needed for oxygen transport. Oxyhemoglobin circulates to the body tissue.

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? Bacterial pneumonia Bronchogenic carcinoma Lung infarction Pleurisy

Pleurisy ---Pleuritic pain from irritation of the parietal pleura is sharp and seems to "catch" on inspiration; patients often describe it as being "like the stabbing of a knife." In carcinoma, the pain may be dull and persistent because the cancer has invaded the chest wall, mediastinum, or spine.

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? Arterial blood gases Pulmonary function test Pulse oximetry Chest x-ray

Pulse ox

The client has just had an invasive procedure to assess the respiratory system. What does the nurse know should be assessed on this client? Watery sputum Loss of consciousness Respiratory distress Masses in pleural space

Respiratory distress ---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 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? Rales Venous hum Rhonchi Bronchovesicular

Rhonchi

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? Crackles Pleural friction rub Rhonchi Bronchial

Rhonchi --are deep, low-pitched, rumbling sounds heard usually on expiration. The etiology of rhonchi is associated with chronic bronchitis.

An 18-month-old child is brought to the Emergency Department by parents who explain that their child swallowed a watch battery. Radiologic studies show that the battery is in the lungs. Which area of lung is the battery most likely to be in? Right upper lung Left upper lung Right lower lung Left lower lung

Right upper lung

In which position should the client be placed for a thoracentesis? Prone Sitting on the edge of the bed Supine Lateral recumbent

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? Medication allergies Swallow reflex Presence of carotid pulse Ability to deep breathe

Swallow reflex

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? --Tickle the back of the throat to produce the gag reflex. --Drink 8 oz of water to thin the secretions for expectoration. --Use the secretions present in the oral cavity. -- Take deep breaths and cough forcefully.

Take deep breaths and cough forcefully. ---Taking deep breaths moves air around the sputum and coughing forcefully moves the sputum up the respiratory tract. Once in the pharynx, the sputum can be expectorated into a specimen container. Producing a gag reflex elicits stomach contents and not respiratory sputum. Dilute and thinned secretions are not helpful in aiding expectoration. A sputum culture is not a component of oral secretions.

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 The frontal lobe Central sulcus Wernicke's area

The Pons ---The pons in the brainstem controls rate and depth of respirations. When injury occurs or increased intracranial pressure results, respirations are slowed. The frontal lobe completes executive functions and cognition. The central sulcus is a fold in the cerebral cortex called the central fissure. The Wernicke's area is the area linked to speech.

You are the hospice nurse caring for a client with pulmonary fibrosis who wants to die at home. The client is having difficulty breathing. The family asks why it is so hard for the client to breathe. What would be the nurse's best response? - "The dying no longer have the energy to breathe." - "This is normal when a person is near the end of their life." -"The fibrosis of the lungs makes the lungs stiff, which makes it harder to breathe. -"The disease is making your loved one retain carbon dioxide, so there is not enough room in the blood for adequate oxygen."

The fibrosis of the lungs makes the lungs stiff, which makes it harder to breathe. ---Decreased surfactant, fibrosis, edema, and atelectasis (alveolar collapse) affect lung compliance. Greater pressure gradients are needed when lungs are stiff.

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. -- The sternum is depressed from the second intercostal space. -- The thoracic and lumbar spine have a lateral S-shaped curvature. --The chest is rounded, ribs are horizontal, and sternum is pulled forward.

The sternum protrudes and the ribs are sloped backward. ---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.

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? Vital capacity Functional residual capacity Tidal volume Maximal voluntary ventilation

Tidal volume ---Tidal volume refers to the volume of air inhaled or exhaled during each respiratory cycle when breathing normally. Normal tidal volume ranges from 400 to 700 ml. Vital capacity refers to the total volume of air that can be exhaled during a slow, maximal expiration after maximal inspiration. Functional residual capacity refers to the volume of air remaining in the lungs after a normal expiration. Maximal voluntary ventilation is the greatest volume of air expired in 1 minute with maximal voluntary effort.

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? Perfusion exceeds ventilation. There is an absence of perfusion and ventilation. Ventilation exceeds perfusion. Ventilation matches perfusion.

Ventilation exceeds perfusion. ---A high ventilation-perfusion rate means that ventilation exceeds perfusion, causing dead space. The alveoli do not have an adequate blood supply for gas exchange to occur. This is characteristic of a variety of disorders, including pulmonary emboli, pulmonary infarction, and cardiogenic shock.

What is the difference between respiration and ventilation? Ventilation is the process of gas exchange. Ventilation is the movement of air in and out of the respiratory tract. Ventilation is the process of getting oxygen to the cells. Ventilation is the exchange of gases in the lung.

Ventilation is the movement of air in and out of the respiratory tract. ---Ventilation is the actual movement of air in and out of the respiratory tract. Respiration is the exchange of oxygen and CO2 between atmospheric air and the blood and between the blood and the cells.

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? Crackles Rhonchi Rubs Wheezes

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? Rales Crackles Wheezes Rhonchi

Wheezes ---Sibilant wheezes are continuous, musical, high-pitched, whistlelike sounds heard during inspiration and expiration caused by air passing through narrowed or partially obstructed airways; they may clear with coughing. Crackles, formerly called rales, are soft, high-pitched, discontinuous popping sounds that occur during inspiration (while usually heard on inspiration, they may also be heard on expiration); they may or may not be cleared by coughing. Rhonchi, or sonorous wheezes, are deep, low-pitched rumbling sounds heard primarily during expiration; they are caused by air moving through narrowed tracheobronchial passages.

Which is an age-related change associated with the respiratory system? Increased chest muscle mass. Thinning of alveolar membranes. Decreased size of the airway. Increased elasticity of alveolar sacs.

decreased size of the airway ---Age-related changes that occur in the respiratory system are a decrease in the size of the airway, decreased chest muscle mass, increased thickening of the alveolar membranes, and decreased elasticity of the alveolar sacs.

During assessment of the respiratory system, the nurse inspects and palpates the trachea in order to assess: trachea? deviation from the midline. evidence of exudate. color of the mucous membranes. evidence of muscle weakness.

deviation from the midline.

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 genetics oropharynx epiglottis

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. is when the body changes oxygen into CO2. provides a blood supply to the lungs. helps people who cannot breathe on their own.

is breathing air in and out of the lungs. ---Ventilation is the actual movement of air in and out of the respiratory tract. Diffusion is the exchange of oxygen and CO2 through the alveolar-capillary membrane. Pulmonary perfusion refers to the provision of blood supply to the lungs. A mechanical ventilator assists patients who are unable to breathe on their own.

What is the primary function of the larynx? producing sound protecting the lower airway from foreign objects facilitating coughing preventing infection

producing sound ---The larynx, or voice box, is a cartilaginous framework between the pharynx and trachea. Its primary function is to produce sound. While the larynx assists in protecting the lower airway, this is mainly the function of the epiglottis. Facilitating coughing is a secondary function of the larynx. Preventing infection is the main function of the tonsils and adenoids.

The term for the volume of air inhaled and exhaled with each breath is residual volume. tidal volume. vital capacity. expiratory reserve volume.

tidal volume ----Tidal volume is the volume of air inhaled and exhaled with each breath. Residual volume is the volume of air remaining in the lungs after a maximum expiration. Vital capacity is the maximum volume of air exhaled from the point of maximum inspiration. Expiratory reserve volume is the maximum volume of air that can be exhaled after a normal inhalation.

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? Pneumonia Funnel chest Emphysema Pigeon chest

Emphysema ---Tactile fremitus is assessed through vibrations of sound on the chest wall by palpation. Normally, fremitus is felt most over the large bronchi and least over the distant lung fields. Clients with emphysema exhibit almost no fremitus, because of the rupture of alveoli and the trapping of air. Air does not conduct sound well.

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 assisting the client to a semi-Fowler's position. -The nursing assistant is assisting the client to the side of the bed to use a urinal. - The nursing assistant is pouring a glass of water to wet the client's mouth. -The nursing assistant is asking a question requiring a verbal response.

The nursing assistant is pouring a glass of water to wet the client's mouth. ---When completing a procedure which sends a scope down the throat, the gag reflex is anesthetized to reduce discomfort. Upon returning to the nursing unit, the gag reflex must be assessed before providing any food or fluids to the client. The client may need assistance following the procedure for activity and ambulation but this is not restricted in the post procedure period.

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? Tympanic Resonant Hyperresonant Dull

Dull --A dull percussed sound, heard over the chest wall, is indicative of little or no air movement in that area of the lung. Lung consolidation such as in pneumonia or fluid accumulation produces the dull sound. A tympanic sound is a high-pitched sound commonly heard over the stomach or bowel. A resonant sound is noted over normal lung tissue. A hyper resonant sound is an abnormal lower pitched sound that occurs when free air exists in disease processes such as pneumothorax.

Which of the following disease processes cause increased compliance? Emphysema Pulmonary fibrosis Pulmonary edema Acute respiratory distress syndrome

Emphysema ---High or increased compliance occurs if the lungs have lost their elasticity (cannot return to normal state) and the thorax is overdistended, as in emphysema. Low or decreased compliance occurs if the lungs and thorax are "stiff" (difficult to stretch). Conditions associated with decreased compliance include pneumothorax, hemothorax, pleural effusion, pulmonary edema, atelectasis, pulmonary fibrosis, and acute respiratory distress syndrome (ARDS).

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 lungs increase respiratory volume. -- The lungs retain more CO2 to lower the pH. -- The kidneys retain more HCO3 to raise the pH.

The lungs eliminate carbonic acid by blowing off more CO2 --To maintain normal pH in critically ill clients, the lungs eliminate carbonic acid by blowing off more CO2. To maintain normal pH in critically ill clients, the lungs conserve CO2 by slowing respiratory volume. The lungs would retain more CO2 during an acid-base imbalance in cases of metabolic alkalosis. The kidneys would retain more HCO3 to compensate during an acid-base imbalance in cases of metabolic acidosis.

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 -Asking the client to say "one, two, three" while the nurse auscultates the lungs -Instructing the client to take a deep breath and hold it while the diaphragm is percussed - Placing the thumbs along the costal margin of the chest wall and instructing the client to inhale deeply

Asking the client to repeat "ninety-nine" as the nurse's hands move down the client's thorax ---While the nurse is assessing for tactile fremitus, the client is asked to repeat "ninety-nine" or "one, two, three," or "eee, eee, eee" as the nurse's hands move down the client's thorax. Vibrations are detected with the palmar surfaces of the fingers and hands, or the ulnar aspect of the extended hands, on the thorax. The hand(s) are moved in sequence down the thorax, and corresponding areas of the thorax are compared. Asking the client to say "one, two, three" while auscultating the lungs is not the proper technique to assess for tactile fremitus. The nurse assesses for anterior respiratory excursion by placing the thumbs along the costal margin of the chest wall and instructing the client to inhale deeply. The nurse assesses for diaphragmatic excursion by instructing the client to take a deep breath and hold it while the diaphragm is percussed.

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 result from air passing through widened air passages. They can be heard during inspiration and expiration. They are heard in clients with decreased secretions. They occur when the pleural surfaces are inflamed.

They can be heard during inspiration and expiration. ---Sibilant or hissing or whistling wheezes are continuous musical sounds that can be heard during inspiration and expiration. They result from air passing through narrowed or partially obstructed air passages and are heard in clients with increased secretions. The crackling or grating sounds heard during inspiration or expiration are friction rubs. They occur when the pleural surfaces are inflamed.