Honan-Chapter 8: Nursing Assessment: Respiratory Function
A patient presents to the emergency room with pulmonary edema. The nurse expects to hear what adventitious sound? A. Decreased breath sounds B. Inspiratory and expiratory wheezing C. Crackles D. Friction rub
C. Crackles RATIONALE Crackles are associated with heart failure.
High or increased compliance occurs in which disease process? Emphysema Pneumothorax Pleural effusion ARDS
Emphysema Explanation: 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).
Before an ABG is drawn from the patient's radial artery, what test should be performed? A. Doppler flow test B. Allen test C. Babinski test D. Ankle Brachial Index (ABI)
B. Allen test RATIONALE The Allen test is used to assess for adequate perfusion of the hand via the ulnar artery prior to puncturing the radial artery for an arterial blood gas. This test assesses patency of the ulnar artery and/or collateral circulation.
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%
Explanation: Normal SpO2 values are more than 95%. Values less than 90% indicate that the tissues are not receiving enough oxygen, in which case further evaluation is needed.
A 15-year-old boy with a history of asthma is undergoing lung function testing after experiencing a series of recent exacerbations. Which of the following instructions would facilitate measurement of the child's inspiratory reserve volume (IRV)? "Take normal, comfortable breaths until I ask you to stop." "Force as much air out of your lungs as you can and then take the deepest breath that you can." "I want you to take a normal breath in and then breathe in as deeply as you possibly can." "Breathe out like you normally would and then immediately breathe out as much as you're able to."
"I want you to take a normal breath in and then breathe in as deeply as you possibly can." Explanation: IRV is the maximum volume of air that can be inhaled after a normal inhalation. Consequently, the patient would be asked to inhale normally and then immediately inhale to the maximum of his or her ability.
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." Explanation: 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.
A patient is admitted to the ICU after falling from a roof and sustaining fractures of the first three ribs on the right side. The patient is dyspneic, and crepitus (subcutaneous emphysema) can be palpated. Auscultation reveals decreased breath sounds on the right. The chest x-ray reveals a pneumothorax. Upon percussion, what does the nurse expect to hear? A. Dullness on the right B. Resonance on the right C. Tympany on the right D. Hyperresonance on the right
D. Hyperresonance on the right RATIONALE Hyperresonance is expected with a pneumothorax due to accumulation of air in the pleural space.
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 Explanation: Fluoroscopy enables the physician to view the thoracic cavity with all of its contents in motion. A fluoroscopy more precisely diagnoses the location of a tumor or lesion. An x-ray shows the size, shape, and position of the lungs. An MRI and CT produce axial views of the lungs.
A client with sinus congestion complains of discomfort when the nurse is palpating the supraorbital ridges. What sinus is the client referring? Frontal Ethmoidal Maxillary Sphenoidal
Frontal Explanation: The nurse may palpate the frontal and maxillary sinuses for tenderness. Using the thumbs, the nurse applies gentle pressure in an upward fashion at the supraorbital ridges (frontal sinuses) and in the cheek area adjacent to the nose (maxillary sinuses). The ethmoidal sinuses are located between the nose and eyes. The sphenoidal sinuses are behind the nose between the eyes.
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 Explanation: Pulse oximetry is a noninvasive method of continuously monitoring the oxygen saturation of hemoglobin. The reading is referred to as SpO2. A probe or sensor is attached to the fingertip, forehead, earlobe, or bridge of the nose. Values less than 85% indicate that the tissues are not receiving enough oxygen. SpO2 values obtained by pulse oximetry are unreliable in states of low perfusion such as hypothermia.
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 relaxes during inspiration. The thoracic cavity becomes smaller during inspiration.
Air is drawn through the trachea and bronchi into the alveoli during inspiration. Explanation: 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.
The nurse knows that what condition is associated with increased compliance of the lungs? Atelectasis Pulmonary edema Emphysema Pleural effusion
Emphysema Explanation: Compliance is normal if the lungs and the thorax easily stretch and distend. Increased compliance occurs if the lungs have lost their elastic recoil and become overdistended as in emphysema. Decreased compliance occurs if the lungs and the thorax are "stiff." Conditions associated with decreased compliance include morbid obesity, pneumothorax, hemothorax, pleural effusion, pulmonary edema, atelectasis, pulmonary fibrosis, and acute respiratory distress syndrome (ARDS). This causes airway collapse during expiration, dyspnea, and eventually cyanosis.
High or increased compliance occurs in which condition? Emphysema Pneumothorax Pleural effusion ARDS
Emphysema Explanation: 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).
The nurse working on the respiratory intensive care unit is aware that several respiratory conditions can affect the compliance of the lung tissue. Which condition leads to an increase in lung compliance? Emphysema Pulmonary fibrosis Pleural effusion Acute respiratory distress syndrome
Emphysema Explanation: High or increased compliance occurs if the lungs have lost their elasticity and the thorax is overdistended, in conditions such as emphysema. Conditions associated with decreased compliance include pneumothorax, hemothorax, pleural effusion, pulmonary edema, atelectasis, pulmonary fibrosis, and acute respiratory distress syndrome.
An emergency department (ED) nurse is caring for a patient complaining of dyspnea. The nurse assesses the patient's chest and hears wheezing throughout the lung fields. What might this indicate? The patient is in bronchospasm. The patient has pneumonia. The patient needs physiotherapy. The patient has a hemothorax.
The patient is in bronchospasm. Explanation: Wheezing is a high-pitched, musical sound heard mainly on expiration (asthma) or inspiration (bronchitis). It is often the major finding in a patient with bronchoconstriction or airway narrowing. Dyspnea (shortness of breath) and wheezing are generally associated with marked bronchospasm. Wheezing is not indicative of pneumonia or hemothorax. Wheezing does not indicate the need for physiotherapy.
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. Explanation: 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. Therefore, options A, C, and D are incorrect.
A patient has a chronic cough with thick sputum. He undergoes a bronchoscopy for diagnostic purposes. Following the bronchoscopy, which action by the nurse is most appropriate? A. Encourage fluid intake to promote elimination of contrast media. B. Monitor hemoglobin and hematocrit to evaluate blood loss. C. Check vital signs every 15 minutes for 4 hours. D. Keep NPO until the gag reflex returns.
D. Keep NPO until the gag reflex returns. RATIONALE Preoperative sedation and local anesthesia impair the protective laryngeal reflex and swallowing for several hours after a bronchoscopy. To prevent aspiration before refeeding the patient, the nurse must reassess the return of the gag reflex (pharyngeal reflex; ninth, tenth cranial nerve).
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 Explanation: 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 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 Explanation: When the minute ventilation falls, alveolar ventilation in the lungs also decreases, and the PaCO2 increases
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.
The client has a funnel chest. Explanation: 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 would not diagnose chronic respiratory disease or pneumonia. The client would also not prescribe a cough suppressant.
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 Explanation: Common causes of cough include asthma, gastrointestinal reflux disease, infection, aspiration, and side effects of medications, such as angiotensin converting enzyme (ACE) inhibitors. The other medications listed are not associated with causing a cough.
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. Explanation: 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.
The finding of normal breath sounds on the right chest and diminished, distant breath sounds on the left chest of a newly intubated patient is probably due to which of the following? A. A left pneumothorax B. A right hemothorax C. Intubation of the right mainstem bronchus D. A malfunctioning mechanical ventilator
C. Intubation of the right mainstem bronchus RATIONALE The right mainstem is wider, shorter (about 2.5 cm long), and more vertical in direction than the left main bronchus; therefore, accidental placement in the right lung is a potential complication. It is imperative that after intubation, the nurse auscultate for the presence of bilateral breath sounds.
During a routine visit to the pulmonologist, a client is told to undergo a mediastinoscopy. After the physician leaves the room, the nurse enters and is asked about this procedure. How should the nurse respond? Exploration and biopsy of the lymph nodes that drain the lungs Aspiration of the fluid that has accumulated around the lungs Injection of radioactive dye to measure the integrity of the lung's blood flow Inspection and examination of the larynx, trachea, and bronchi
Exploration and biopsy of the lymph nodes that drain the lungs Explanation: A mediastinoscopy is the endoscopic examination of the mediastinum for exploration and biopsy of mediastinal lymph nodes that drain the lungs. The remaining options are explanations of other pulmonary diagnostic studies.
A nurse is receiving change-of-shift report about an older adult patient who has a diagnosis of chronic obstructive pulmonary disease (COPD). The nurse's colleague reports that she has applied oxygen at 6 L/min by nasal prongs in an effort to bring the patient's oxygen saturation levels above 92%. How should the nurse best interpret this colleague's action? Supplementary oxygen should not normally be given to patients who have a history of COPD. The patient should be given oxygen by simple face mask rather than by nasal prongs. Giving oxygen at a high rate has the potential to interfere with the patient's hypoxic drive. The patient will require 2 to 3 hours of oxygen therapy before an increase in oxygen saturation occurs.
Giving oxygen at a high rate has the potential to interfere with the patient's hypoxic drive. Explanation: If oxygen is administered at a high enough rate to raise the PaO2 to normal in a patient with COPD, there is a risk of obliterating the hypoxic drive. Thus, low-flow oxygen is administered to a patient with COPD, while the nurse carefully assesses for complications. The use of a face mask does not mitigate this risk, and there is no 2- or 3-hour lag between oxygen administration and changes in oxygen saturation levels.
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 Explanation: The diaphragm separates the thoracic and abdominal cavities. On inspiration, the diaphragm contracts and moves downward, creating a partial vacuum. Without this vacuum, air is not as efficiently drawn into the thoracic cavity. Hypoxia or hypoxemia may occur from the poor availability of oxygen. Although the nursing diagnosis Acute Pain is probable, gas exchange is a higher priority. Ineffective Airway Clearance is the least concern because the problem is with ventilation.
A pediatrician diagnosed a child with swollen and inflamed adenoids. The nurse practitioner confirmed the diagnosis by: Palpating the throat above the cricoid cartilage. Inspecting the roof of the nasopharynx. Examining the base of the oropharynx. Inspecting the posterior region of the epiglottis.
Inspecting the roof of the nasopharynx. Explanation: The adenoids are clusters of lymph tissue located between the back of the nose and the back of the throat in the nasopharynx. The adenoids are usually inspected by using a special mirror. They cannot be seen by looking directly into the mouth.
A patient exhibited signs of an altered ventilation-perfusion ratio. The nurse is aware that adequate ventilation but impaired perfusion exists when the patient has which of the following conditions? Atelectasis Infective process Tumor Pulmonary embolism
Pulmonary embolism Explanation: When a blood clot exists in a pulmonary vessel (embolus), impaired perfusion results. However, ventilation is adequate. With the other choices, ventilation is impaired but perfusion is adequate.
Which ventilation-perfusion ratio is exhibited by acute respiratory distress syndrome (ARDS)? Silent unit Dead space Low ventilation-perfusion ratio Normal ratio of perfusion to ventilation
Silent unit Explanation: When ventilation exceeds perfusion a dead space exists. An example of a dead space is a pulmonary emboli. A low ventilation-perfusion ratio exists in pneumonia or with a mucus plug. A silent unit occurs in pneumothorax or ARDS.
The nurse is providing care for a 60-year-old patient who has been admitted for the treatment of community-acquired pneumonia. The nurse reads in the patient's chart that he has an 80 pack-year history of cigarette smoking. During health education about smoking cessation, the patient tells the nurse that he began smoking as a 20-year-old when he was conscripted into the army. What conclusion can the nurse draw from these data? The patient smokes four packs of cigarettes each day. The patient has been smoking two packs a day for most of his adult life. The patient is extremely unlikely to be able to stop smoking. The patient is unaware of the health consequences of smoking.
The patient has been smoking two packs a day for most of his adult life. Explanation: Pack years are calculated by the number of packs smoked per day times the years the individual has smoked. Despite this patient's extensive smoking history, it would be incorrect to presume that smoking cessation is an impossibility. As well, it is wrong to presume that he has been unaware of the consequences of smoking.
The nurse documents breath sounds that are soft, with inspiratory sounds longer than expiratory and found over the periphery of the lungs. Which of the following will the nurse chart? Adventitious Tracheal Bronchial Vesicular
Vesicular Explanation: Vesicular breath sounds are heard over the entire lung field except the upper sternum and between the scapulae. Their pitch and intensity are low. Inspiration sounds are longer than expiratory sounds. These are considered normal breath sounds.
