PrepU: Chapter 20

The nurse is assessing the lungs of a patient diagnosed with pulmonary edema. Which of the following would be expected upon auscultation? Crackles at lung bases Egophony Absent breath sounds Bronchial breath sounds

Crackles at lung bases A patient with pulmonary edema would be expected to have crackles in the lung bases, and possible wheezes. Egophony may occur in patients diagnosed with pleural effusion. Absent breath sounds occurs in pneumothorax. Bronchial breath sounds occur in consolidation, such as pneumonia.

Which of the following are age-related structural and functional changes that occur in the respiratory system? Select all that apply. Decreased pulmonary compliance Decreased elasticity of the alveolar sacs Increased residual volume Increased diameter of alveolar ducts Decreased dead space Increased thickness of alveolar sacs

Increased residual volume Decreased elasticity of the alveolar sacs Increased thickness of alveolar sacs Increased diameter of alveolar ducts

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 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 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 would not diagnose chronic respiratory disease or pneumonia. The client would also not prescribe a cough suppressant.

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 Smoking history is usually expressed in pack-years, which is the number of packs of cigarettes smoked per day times the number of years the patient smoked. In this situation, the client's pack-years is 22 (2 × 11). It is important to find out whether the client is still smoking or when the client quit smoking.

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. Observing the rate and depth of respiration is an important aspect of a nursing assessment. The normal adult resting respiratory rate is 12 to 18 breaths per minute. Tachypnea is rapid breathing with a rate greater than 24 breaths per minute. An increase in the rate of respirations needs further investigation and must be reported.

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? Respiratory rate Cyanosis Son's statement Crackles

Cyanosis The client's appearance may give clues to respiratory status. Cyanosis, a bluish coloring of the skin, is a very late indicator of hypoxia. The presence of cyanosis is from decreased unoxygenated hemoglobin. In the presence of a pulmonary condition, cyanosis is assessed by observing the color of the tongue and lips.

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 To palpate the maxillary sinuses, the nurse should apply gentle pressure in the cheek area below the eyes, adjacent to the nose.

A nurse is preparing a client with a pleural effusion for a thoracentesis. The nurse should: assist the client to a sitting position on the edge of the bed, leaning over the bedside table. raise the arm on the side of the client's body on which the physician will perform the thoracentesis. place the client supine in the bed, which is flat. raise the head of the bed to a high Fowler's position.

assist the client to a sitting position on the edge of the bed, leaning over the bedside table A physician usually performs a thoracentesis when the client is sitting in a chair or on the edge of the bed, with the legs supported and the arms folded and resting on a pillow or on the bedside table. Raising an arm, lying supine, or raising the head of the bed won't allow the physician to easily access the thoracic cavity.

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.

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 young adult visited a clinic because he was injured during a softball game. He told the nurse that the ball struck him in his "Adam's apple." To assess the initial impact of injury, the nurse: Inspects the vocal cords. Inspects the epiglottis. Palpates the thyroid cartilage. Palpates the cricoid cartilage.

Palpates the thyroid cartilage The term "Adam's Apple" is used to refer to a lump or protrusion, a laryngeal prominence. It is formed by the angle of the thyroid cartilage surrounding the larynx.

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.

A nurse assesses a client's respiratory status. Which observation indicates that the client is having difficulty breathing? Diaphragmatic breathing Use of accessory muscles Pursed-lip breathing Controlled breathing

Use of accessory muscles The use of accessory muscles for respiration indicates the client is having difficulty breathing. Diaphragmatic and pursed-lip breathing are two controlled breathing techniques that help the client conserve energy.

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.