Respiratory: Ch. 20

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? A. Cyanosis B. Confusion C. Restlessness D. Dyspnea

A. Cyanosis

Which hollow tube transports air from the laryngeal pharynx to the bronchi? A. trachea B. larynx C. bronchioles D. pharynx

A. trachea

What would the instructor tell the students purulent fluid indicates? A. Inflammation B. Cancer C. Heart failure D. Infection

D. Infection

What is the primary function of the larynx? A. Producing sound B. Preventing infection C. Facilitating coughing D. Protecting the lower airway from foreign objects

A. Producing sound

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? A. Bronchiectasis B. An infection with pneumococcal pneumonia C. A lung abscess D. Bronchitis

B. An infection with pneumococcal pneumonia

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

B. Ventilation is the movement of air in and out of the respiratory tract.

A client has been newly diagnosed with emphysema. The nurse should explain to the client that by definition, ventilation: A. is when the body changes oxygen into CO2. B. is breathing air in and out of the lungs. C. helps people who cannot breathe on their own. D. provides a blood supply to the lungs.

B. is breathing air in and out of the lungs.

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? A. Placement of the probe on an earlobe B. Increased temperature of the room C. Diagnosis of peripheral vascular disease D. Reduced lighting in the room

C. Diagnosis of peripheral vascular disease

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? A. The frontal lobe B. Central sulcus C. The pons D. Wernicke's area

C. The pons

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

C. assist the client to a sitting position on the edge of the bed, leaning over the bedside table

Upon palpation of the sinus area, what would the nurse identify as a normal finding?

No sensation during palpation

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

Orthopnea

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: A. Palpates the cricoid cartilage. B. Palpates the thyroid cartilage. C. Inspects the vocal cords. Inspects the epiglottis.

Palpates the thyroid cartilage.

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

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

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. A puncture at the radial artery B. The trachea and bronchi C. A catheter in the arm vein D. The pleural surfaces

A. A puncture at the radial artery

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

A. Assess the client for a cough reflex.

Which of the following clinical manifestations should a nurse monitor for during a pulmonary angiography, which indicates an allergic reaction to the contrast medium? A. Difficulty in breathing B. Hematoma C. Urge to cough D. Absent distal pulses

A. Difficulty in breathing

During a preadmission assessment, for what diagnosis would the nurse expect to find decreased tactile fremitus and hyperresonant percussion sounds? A. Emphysema B. Atelectasis C. Pulmonary edema D. Bronchitis

A. Emphysema

A nurse is concerned that a client may develop postoperative atelectasis. Which nursing diagnosis would be most appropriate if this complication occurs? A. Impaired gas exchange B. Decreased cardiac output C. Ineffective airway clearance D. Impaired spontaneous ventilation

A. Impaired gas exchange

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? A. Ventilation exceeds perfusion. B. There is an absence of perfusion and ventilation. C. Perfusion exceeds ventilation. D. Ventilation matches perfusion.

A. Ventilation exceeds perfusion.

While auscultating the lungs of a client with asthma, the nurse hears a continuous, high-pitched whistling sound on expiration. The nurse will document this sound as which of the following? A. Wheezes B. Crackles C. Rhonchi D. Pleural friction rub

A. Wheezes

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? A. Asthma B. Pneumothorax C. Adult respiratory distress syndrome D. Acute respiratory obstruction

A. asthma

While conducting the physical examination during assessment of the respiratory system, which conditions does the nurse assess by inspecting and palpating the trachea? A. Evidence of exudate B. Deviation from the midline C. Evidence of muscle weakness D. Color of the mucous membranes

B. Deviation from the midline

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

B. On the cheeks below the eyes

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

B. The nursing assistant is pouring a glass of water to wet the client's mouth.

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

B. They can be heard during inspiration and expiration.

The volume of air inhaled and exhaled with each breath is termed A. vital capacity. B. tidal volume. C. residual volume. D. expiratory reserve volume.

B. tidal volume.

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? A. Excessive capillary refill B. Flushed feeling in the client C. Absent distal pulses D. Raised temperature in the affected limb

C. Absent distal pulses

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? A. Anterior bronchial tree B. Posterior bronchioles C. Bilateral lower lobes D. Right lower lobe

C. Bilateral lower lobes

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

C. Count the rate of respirations.

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

C. Lungs are clear on auscultation.

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

C. Warm and humidify inspired air

The nurse is caring for clients on the neurological unit. Which triad of neurological mechanisms does the nurse identify as most responsible when there is abnormality in ventilation control? A. Medulla oblongata, cerebellum, and heart rate B. Pons, cerebellum, and oxygen receptors C. Medulla oblongata, mitral valve, and central receptors D. Aortic arch, pons, and CO2 receptor sites

D. Aortic arch, pons, and CO2 receptor sites

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? A. Tympanic B. Hyperresonant C. Resonant D. Dull

D. Dull

What happens to the diaphragm during inspiration? A. It contracts and raises. B. It relaxes and raises. C. It relaxes and flattens. D. It contracts and flattens.

D. It contracts and flattens.

When assessing a client, which adaptation indicates the presence of respiratory distress? A. Productive cough B. Respiratory rate of 14 breaths per minute C. Sore throat D. Orthopnea

D. Orthopnea

The clinical finding of pink, frothy sputum may be an indication of which condition? A. Infection B. Bronchiectasis C. Lung abscess D. Pulmonary edema

D. Pulmonary edema

A client with chronic bronchitis is admitted to the health facility. Auscultation of the lungs reveals low-pitched, rumbling sounds. What breath sound should the nurse document? A. Bronchovesicular B. Venous hum C. Rales D. Rhonchi

D. Rhonchi

A nurse is assessing a client's respiratory system. Which alveolar cells secrete surfactant to reduce lung surface tension? A. Macrophages B. Type IV C. Type I D. Type II

D. Type II

A nurse is discussing squamous epithelial cells lining each alveolus, which consist of different types of cells. Which type of alveolar cells produce surfactant? A. Type III cells B. Type IV cells C. Type I cells D. Type II cells

D. Type II cells

A patient diagnosed with diabetic ketoacidosis would be expected to have which type of respiratory pattern?

Kussmaul respirations