Ch 20

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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

A nurse would question the accuracy of a pulse oximetry evaluation in which of the following conditions?

A client experiencing hypothermia

A nurse is concerned that a client may develop postoperative atelectasis. Which nursing diagnosis would be most appropriate if this complication occurs?

Impaired gas exchange

While conducting the physical examination during assessment of the respiratory system, which conditions does the nurse assess by inspecting and palpating the trachea?

Deviation from the midline

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

A nurse is preparing a client for bronchoscopy. Which instruction should the nurse give to the client?

Do not eat or drink for 6 hours before the procedure.

When assessing a client, which adaptation indicates the presence of respiratory distress?

Orthopnea

Bradypnea is associated with which condition?

Increased intracranial pressure

The nurse is in the radiology unit of the hospital. The nurse is caring for a client who is scheduled for a lung scan. The nurse knows that lung scans need the use of radioisotopes and a scanning machine. Before the perfusion scan, what must the client be assessed for?

Iodine allergy

Why is it important for a nurse to provide required information and appropriate explanations of diagnostic procedures to patients with respiratory disorders?

Manage decreased energy levels

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

No sensation during palpation

Which term will the nurse use to document the inability of a client to breathe easily unless positioned upright?

Orthopnea

What is the primary function of the larynx?

Producing sound

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 pouring a glass of water to wet the client's mouth.

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

What is the difference between respiration and ventilation?

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

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?

Wheezes

A nonverbal client has just finished undergoing a bronchoscopy procedure and writes that he want to eat lunch now. Which intervention is necessary for the nurse to complete at this time?

assess for cough reflex

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?

asthma

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?

cyanosis

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

What would the instructor tell the students purulent fluid indicates?

infection

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

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?

pleurisy

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?

wheezes


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