CH 27 - Assessment of the Respiratory System

Which assessment findings are most important for the nurse to determine when assessing a client with dyspnea? Select all that apply. A. Onset of or when the client first noticed dyspnea B. Results of most recent pulmonary function test C. Conditions that relieve the dyspnea sensation D. Whether or not dyspnea interferes with ADLs E. Inspection of the external nose and its symmetry F. Whether stridor is present with dyspnea

A C D F

What observations does the nurse make when performing a general assessment of a patient's lungs and thorax? Select all that apply. a. Symmetry of chest movement b. Rate, rhythm, and depth of respirations c. Use of accessory muscles for breathing d. Comparison of the anteroposterior diameter with the lateral diameter e. Measurement of the length of the chest cavity f. Assessment of chest expansion and respiratory excursion

A, B, C, D, F

The nurse is assessing a middle-aged patient who reports a decreased tolerance for exercise and that she must work harder to breathe. Which questions assist the nurse in determining what these changes are related to? Select all that apply. a. "Do you have anemia?" b. "When did you first notice these symptoms?" c. "Do you or have you ever smoked cigarettes?" d. "How often do you exercise?" e. "Are you coughing up any colored sputum?" f. "Does your sputum clear with coughing?"

A, B, C, E

For what reasons would a patient have a bronchoscopy? Select all that apply. a. Obtain samples for cultures b. Diagnose pulmonary disease c. View upper airway structures d. Administer medications e. Obtain samples for biopsy f. Lung cancer staging

A, B, E, F

Which conditions are most likely to cause a "left shift" of the oxyhemoglobin dissociation curve? Select all that apply. A. Reduced blood and tissue levels of diphosphoglycerate (DPG) B. Reduced blood and tissue pH C. Increased metabolic demands D. Alkalosis E. Increased body temperature F. Reduced blood and tissue levels of oxygen

A. Reduced blood and tissue levels of diphosphoglycerate (DPG) D. Alkalosis

The nurse assessing the respiratory status of a client discovers that tactile fremitus has increased from the assessment performed yesterday. For which possible respiratory problem should the nurse assess further? A. Pneumothorax B. Pneumonia C. Pleural effusion D. Emphysema

B. Pneumonia

Which description of respiratory physiologic features is correct? A. The elastic tissues of the tracheobronchial tree are the major structures responsible for gas exchange. B. The epiglottis closes during speech to divert air movement into and through the vocal cords to produce sound. C. Any problem with the right lung interferes with gas exchange and perfusion to a greater degree than a problem in the left lung. D. The left lung is responsible for approximately 60% of gas exchange, and the right lung is responsible for 60% of pulmonary perfusion.

C. Any problem with the right lung interferes with gas exchange and perfusion to a greater degree than a problem in the left lung.

Which factor is the most common cause of chronic respiratory problems and physical limitations? a. Exposure to coal dust b. Decreased strength of respiratory muscles c. Use of smokeless products such as chewing tobacco D. Smoking cigarettes or exposure to cigarette smoke

D. Smoking cigarettes or exposure to cigarette smoke

A patient comes to the health care provider's office for an annual physical. The patient reports a persistent, nagging cough. Which question does the nurse ask first about this symptom? a. "How long has your cough been present?" b. "Do you have a family history of lung c. "Have you been running a fever?" d. "Do you have sneezing and congestion?"

a. "How long has your cough been present?"

Which statement made by a patient who is a smoker indicates the need for additional teaching? a. "I don't worry about lung problems because I don't smoke, but my husband smokes." b. "I worry about lung diseases because I borrow cigarettes when I'm out with friends c. "I use a hookah when I smoke but I'm trying to quit because I know it's not good for me." d. "I'm using e-cigarettes to try to stop smoking but I worry because I don't know the long-term effects."

a. "I don't worry about lung problems because I don't smoke, but my husband smokes."

The nurse teaches a patient who wants to quit smoking about the impact of cigarette smoking on the lower respiratory tract. Which statement by the patient indicates an understanding of the information? a. "Using nicotine replacement therapy will increase my chances of success." b. "If I stop smoking, the damage to my lungs will be reversed." c. "Cigarette smoke affects my ability to cough out secretions from the lungs." d. "Smoking makes the large and small airways get bigger."

a. "Using nicotine replacement therapy will increase my chances of success."

The nurse is performing a respiratory assessment on an older adult patient. Which questions would the nurse be sure to ask? Select all that apply. a. "When was your last chest x-ray?" b. "Do you now or have you ever smoked?" c. "Have you had influenza or pneumonia vaccinations?" d. "Do you have enough energy to do what you like to do?" e. "When was the last time you had a tetanus shot?" f. "Does anyone in your family have a history of chronic illnesses?"

a. "When was your last chest x-ray?" b. "Do you now or have you ever smoked?" c. "Have you had influenza or pneumonia vaccinations?" d. "Do you have enough energy to do what you like to do?"

The nurse has received a patient from the recovery room who is somewhat drowsy but is capable of following instructions. Pulse oximetry has dropped from 95% to 90%. What is the priority nursing intervention? a. Administer oxygen at 2 L/min by nasal cannula, then reassess. b. Have the patient perform coughing and deep-breathing exercises, then reassess. c. Administer naloxone to reverse narcotic sedation effect. d. Withhold narcotic pain medication to reduce sedation effect

a. Administer oxygen at 2 L/min by nasal cannula, then reassess.

A patient is scheduled to have a pulmonary function test (PFT). Which type of information does the nurse include in the nursing history so that PFT results can be appropriately determined? a. Age, gender, race, height, weight, and smoking status b. Occupational status, activity tolerance for activities of daily living c. Medication history and history of allergies to contrast media d. History of chronic medical conditions and surgical procedures

a. Age, gender, race, height, weight, and smoking status

After a bronchoscopy procedure, the patient coughs up sputum that contains blood. What is the best nursing action at this time? a. Assess vital signs and respiratory status and notify the provider of the findings. b. Monitor the patient for 24 hours to see if blood continues in the sputum. c. Send the sputum to the lab for cytology for possible lung cancer. d. Reassure the patient that this is a normal response after a bronchoscopy.

a. Assess vital signs and respiratory status and notify the provider of the findings.

A patient has undergone a percutaneous lung biopsy. After the procedure, what tests may be ordered to confirm that there is no pneumothorax? Select all that apply. a. Computed tomography b. Pulmonary function test c. Magnetic resonance imaging d. Digital chest radiography e. Chest x-ray f. Fluoroscopy

a. Computed tomography f. Fluoroscopy

In the older adult, there is a decreased number of functional alveoli. To assist the patient to compensate for this change related to aging, what does the nurse do? a. Encourage the patient to ambulate and change positions. b. Allow the patient to rest and sleep frequently. c. Have face-to-face conversations when possible. d. Obtain an order for supplemental oxygen.

a. Encourage the patient to ambulate and change positions.

What conditions shift the oxyhemoglobin dissociation curve to the right? Select all that apply. a. Increased carbon dioxide concentration b. Chronic hypoxia c. Increased tissue pH (alkalosis) d. Decreased tissue temperature e. Decreased tissue pH (acidosis) f. Increased body temperature

a. Increased carbon dioxide concentration b. Chronic hypoxia e. Decreased tissue pH (acidosis) f. Increased body temperature

The nurse reviews the complete blood count results for the patient who has chronic obstructive pulmonary disease (COPD) and lives in a high mountain area. What lab results does the nurse expect to see for this patient? a. Increased red blood cells b. Decreased neutrophils c. Decreased eosinophils d. Increased lymphocytes

a. Increased red blood cells

When blood passes through the lungs, what happens to oxygen? a. It diffuses from the alveoli into the red blood cells. b. It diffuses from the red blood cells into the alveoli. c. It decreases concentration in the blood. d. It increases concentration in the alveoli.

a. It diffuses from the alveoli into the red blood cells.

The nurse is taking a history on a patient who reports sleeping in a recliner chair at night because lying on the bed causes shortness of breath. How is this documented? a. Orthopnea b. Paroxysmal nocturnal dyspnea c. Orthostatic nocturnal dyspnea d. Tachypnea

a. Orthopnea

The nurse is reviewing the arterial blood gas results for a 25-year-old trauma patient who has new-onset shortness of breath and demonstrates shallow and irregular respirations. The arterial blood gas results are pH 7.26, Pco2 47%, Po2 89%, HCO3- 24. What imbalance does the nurse suspect this patient has? a. Respiratory acidosis b. Respiratory alkalosis c. Metabolic acidosis d. Metabolic alkalosis

a. Respiratory acidosis

The nurse is providing care for a patient who would like to quit smoking. Which important teaching points must be included when teaching this patient? Select all that apply. a. Talk with your health care provider about nicotine replacement therapies. b. Ask for help from family and friends who have quit smoking. c. Smoking while using a nicotine patch is acceptable as long as you are gradually decreasing how much you smoke. d. Remove all ashtrays, cigarettes, pipes, cigars, and lighters from your home to decrease the temptation to smoke. e. If you are used to having a cigarette after eating, get up from the table as soon as you are finished eating. f. Avoid starting an exercise program at the same time you quit smoking because making two big changes at the same time is setting yourself up for failure.

a. Talk with your health care provider about nicotine replacement therapies. b. Ask for help from family and friends who have quit smoking. d. Remove all ashtrays, cigarettes, pipes, cigars, and lighters from your home to decrease the temptation to smoke. e. If you are used to having a cigarette after eating, get up from the table as soon as you are finished eating. f. Avoid starting an exercise program at the same time you quit smoking because making two big changes at the same time is setting yourself up for failure.

Which procedure has a risk for the complication of pneumothorax? a. Thoracentesis b. Use of incentive spirometry c. Pulmonary function test (PFT) d. Ventilation-perfusion scan

a. Thoracentesis

A patient reports smoking a pack of cigarettes a day for 9 years. He quit for 2 years and then smoked 2 packs a day for the last 30 years. What are the pack-years for this patient? a. 39 years b. 69 years c. 19.5 years d. 41 years

b. 69 years

A patient having respiratory difficulty has a pH of 7.48. What is the nurse's best interpretation of this value? a. Acidosis b. Alkalosis c. Hypoxia d. Hypercarbia

b. Alkalosis

Which description best explains residual volume (RV)? a. Amount of air in the lungs at the end of maximal inhalation b. Amount of air remaining in the lungs at the end of full forced exhalation c. Amount of air remaining in the lungs after normal exhalation d. Maximal amount of forced air that can be exhaled after maximal inspiration

b. Amount of air remaining in the lungs at the end of full forced exhalation

The nurse is performing a respiratory assessment including pulse oximetry on several patients. Which conditions or situations may cause an artificially low reading? Select all that apply. a. Fever b. Anemia c. Receiving narcotic pain medications d. Peripheral artery disease e. History of respiratory disease such as cystic fibrosis or tuberculosis f. Edema

b. Anemia d. Peripheral artery disease f. Edema

The nurse is assisting the health care provider to perform a thoracentesis. What does the nurse do prior to the beginning of the procedure? a. Position the patient in semi-Fowler's position. b. Apply goggles and mask to prevent oral or eye splashes. c. Provide a bottle without a vacuum for specimen collection. d. Shave the patient's entire back.

b. Apply goggles and mask to prevent oral or eye splashes.

The nurse is caring for a patient with dyspnea described as fair to moderate with activity. The patient has no dyspnea at rest. He sometimes experiences dyspnea while showering or dressing and has to stop to catch his breath when going up a flight of stairs. The nurse recognizes that the patient has which class of dyspnea? a. Class II b. Class III c. Class IV d. Class V

b. Class III

Which aspect of pulmonary function testing (PFT) would be considered a normal result in the older adult? a. Increased forced vital capacity b. Decline in forced expiratory volume in 1 second c. Decrease in diffusion capacity of carbon monoxide d. Increased functional residual capacity

b. Decline in forced expiratory volume in 1 second

Which respiratory changes occur as a result of aging? Select all that apply. a. Increased elastic recoil b. Dilation of alveolar ducts c. Decreased ability to cough d. Alveolar surface tension increases e. Diffusion capacity decreases f. Diaphragm muscle strength decreases

b. Dilation of alveolar ducts c. Decreased ability to cough e. Diffusion capacity decreases f. Diaphragm muscle strength decreases

The nurse hears fine crackles during a lung assessment of the patient who is in the initial postoperative period. Which nursing intervention helps relieve this respiratory problem? a. Monitor the patient with a pulse oximeter. b. Encourage coughing and deep-breathing. c. Obtain an order for a chest x-ray. d. Obtain an order for high-flow oxygen.

b. Encourage coughing and deep-breathing.

The nurse is caring for an older adult who uses a wheelchair and spends over half of each day in bed. Which intervention is important in promoting pulmonary hygiene related to age and decreased mobility? a. Obtain an order for as-needed (prn) oxygen via nasal cannula. b. Encourage the patient to turn, cough, and deep-breathe. c. Reassure the patient that immobility is temporary. d. Monitor the respiratory rate and check pulse oximetry readings.

b. Encourage the patient to turn, cough, and deep-breathe.

The nurse is explaining third-hand passive smoking to a patient. Which explanation is most accurate? a. Sitting in a car with a person who is smoking b. Exposure to smoke on the clothes of a smoker c. Walking through a group of people smoking outside d. Entering a room where several people have been smoking

b. Exposure to smoke on the clothes of a smoker

What is the priority medical-surgical concept for the nurse when performing an assessment of a patient's respiratory system? a. Perfusion b. Gas exchange c. Acid-base balance d. Cellular regulation

b. Gas exchange

In which situation would the oxygen- hemoglobin dissociation curve shift to the left? a. Decreased pH (acidosis) b. Increased pH (alkalosis) c. Increased body temperature d. Increased body carbon dioxide concentration

b. Increased pH (alkalosis)

The nurse makes observations about several respiratory patients' abilities to perform activities of daily living in order to quantify the level of dyspnea. Which patient is considered to have class V dyspnea? a. Experiences subjective shortness of breath when walking up a flight of stairs b. Limited to bed or chair and experiences shortness of breath at rest c. Can independently shower and dress but cannot keep pace with similarly aged people d. Experiences shortness of breath during aerobic exercise such as jogging

b. Limited to bed or chair and experiences shortness of breath at rest

While auscultating lung sounds in the anterior chest, the nurse hears moderately loud sounds on inspiration that are equal in length with expiration. In what area is this lung sound considered normal? a. Trachea b. Major bronchi c. Lung fields d. Larynx

b. Major bronchi

Which factors or conditions cause a decreased (below normal) partial pressure of end-tidal carbon dioxide (PEtCO2) level due to poor pulmonary ventilation? Select all that apply. a. Hyperthermia b. Malpositioned endotracheal tube c. Apnea d. Hypoventilation e. Airway obstruction f. Pulmonary embolism

b. Malpositioned endotracheal tube c. Apnea e. Airway obstruction f. Pulmonary embolism

Which groups of people are at high risk for nicotine addiction from smoking? Select all that apply. a. White collar workers b. Native Americans and African Americans c. College graduates d. Women who work full time e. Gay and lesbian people f. High school dropouts

b. Native Americans and African Americans d. Women who work full time e. Gay and lesbian people f. High school dropouts

Which substances from cigarette smoke have been implicated in the development of serious lung diseases? Select all that apply. a. Carbon dioxide b. Nicotine c. Tar d. Carbon monoxide e. Dust particles f. Nitrogen

b. Nicotine c. Tar d. Carbon monoxide

The nurse is reviewing arterial blood gas (ABG) results from an 86-year-old patient. Which results would be considered normal findings for a patient of this age? a. Normal pH, normal Pao2, normal Paco2 b. Normal or acidotic pH, decreased Pao2, normal Paco2 c. Normal or alkalotic pH, decreased Pao2, normal Paco2 d. Decreased pH, decreased Pao2, decreased Paco2

b. Normal or acidotic pH, decreased Pao2, normal Paco2

The respiratory therapist consults with and reports to the nurse that a patient is producing frothy pink sputum. What does the nurse suspect is occurring with this patient? a. Pneumothorax b. Pulmonary edema c. Pulmonary infection d. Pulmonary infarction

b. Pulmonary edema

A patient demonstrates labored, shallow respirations and a respiratory rate of 32/min with a pulse oximetry reading of 85%. What is the priority nursing intervention? a. Notify respiratory therapy to give the patient a breathing treatment. b. Start oxygen via nasal cannula at 2 L/min. c. Obtain an order for a stat arterial blood gas (ABG). d. Encourage coughing and deep-breathing exercises.

b. Start oxygen via nasal cannula at 2 L/min.

Before a bronchoscopy procedure, the patient received benzocaine spray as a topical anesthetic to numb the oropharynx. The nurse is assessing the patient after the procedure. Which finding suggests that the patient is developing methemoglobinemia? a. The patient has a decreased hematocrit level. b. The patient has cyanosis that does not respond to supplemental oxygen. c. The blood sample is a bright cherry-red color. d. The patient experiences sedation and amnesia.

b. The patient has cyanosis that does not respond to supplemental oxygen.

The patient is scheduled for a computed tomography (CT) scan. Which priority question must the nurse be sure to ask before the procedure? a. "Do you have a history of any form of cancer?" b. "Have you ever had a CT scan before?" c. "Are you allergic to iodine or shellfish?" d. "Can you lie very still for at least an hour or more?"

c. "Are you allergic to iodine or shellfish?"

While assessing a patient's chest and lung fields, the nurse notes rapid heart rate, rapid shallow respirations, tracheal deviation toward the right side, and new-onset nagging cough. What is the nurse's priority action? a. Document this expected finding and apply oxygen after checking pulse oximetry. b. Notify the health care provider because the patient has an airway obstruction. c. Assess the patient for air hunger or pain at the end of inhalation and exhalation. d. Palpate for crackling sensation underneath the skin or for localized tenderness.

c. Assess the patient for air hunger or pain at the end of inhalation and exhalation.

A patient's pulse oximetry reading is 89%. What is the nurse's first priority action? a. Recheck the reading with a different oximeter. b. Apply supplemental oxygen and recheck the oximeter reading in 45 minutes. c. Assess the patient for respiratory distress and recheck the oximeter reading. d. Place the patient in the recovery position and monitor frequently.

c. Assess the patient for respiratory distress and recheck the oximeter reading.

A patient who received a bronchoscopy was nothing by mouth (NPO) for several hours before the test. A few hours after the test, the patient is hungry and would like to eat a meal. What does the nurse do before allowing the patient to eat? a. Order a meal because the patient is now alert and oriented. b. Check pulse oximetry to be sure oxygen saturation has returned to normal. c. Check for a gag reflex before allowing the patient to eat. d. Assess for nausea from the medications given for the test.

c. Check for a gag reflex before allowing the patient to eat.

Which structure protects the patient from the risk of aspiration? a. Larynx b. Glottis c. Epiglottis d. Cricoid cartilage

c. Epiglottis

Upon assessing the lungs, the nurse hears short, discrete popping sounds "like hair being rolled between fingers near the ear" in the bilateral lower lobes. How is this assessment documented? a. Rhonchi b. Wheezes c. Fine crackles d. Coarse crackles

c. Fine crackles

A patient reports fatigue and shortness of breath when getting up to walk to the bathroom; however, the pulse oximetry reading is 99%. Which laboratory value is consistent with the patient's subjective symptoms? a. Blood urea nitrogen (BUN) of 15 mg/dL b. White blood cell count (WBC) of 8000/mm3 c. Hemoglobin of 9 g/dL d. Blood glucose 160 mg/dL

c. Hemoglobin of 9 g/dL

The nurse is inspecting a patient's chest and observes an increase in anteroposterior diameter of the chest. When is this an expected finding? a. With a pulmonary mass b. Upon deep inhalation c. In older adult patients d. With chest trauma

c. In older adult patients

The nurse is palpating a patient's chest and identifies an increased tactile fremitus or vibration of the chest wall produced when the patient speaks. What does the nurse do next? a. Observe for other findings associated with subcutaneous emphysema. b. Document the observation as an expected normal finding. c. Observe the patient for other findings associated with a pneumothorax. d. Document the observation as a pleural friction rub.

c. Observe the patient for other findings associated with a pneumothorax.

A patient who had a thoracentesis is now experiencing rapid shallow respirations, rapid heart rate, and pain on the affected side that is worse at the end of inhalation. What complication does the nurse suspect this patient has developed? a. Hemoptysis b. Lung abscess c. Pneumothorax d. Lung cancer

c. Pneumothorax

What is the best position for a patient to assume for a thoracentesis? a. Side-lying, affected side exposed, head slightly raised b. Lying flat with arm on affected side across the chest c. Sitting up, leaning forward on the over-bed table d. Prone position with arms above the head

c. Sitting up, leaning forward on the over-bed table

Which sounds in the smaller bronchioles and the alveoli indicate normal lung sounds? a. Harsh, hollow, and tubular blowing b. Nothing; normally no sounds are heard c. Slow, low rustling; like wind in the trees d. Flat, dull tones with a moderate pitch

c. Slow, low rustling; like wind in the trees

Pulmonary function tests are scheduled for a patient with a history of smoking who reports dyspnea and chronic cough. What will patient teaching information about this procedure include? a. Do not smoke for at least 2 weeks before the test. b. Bronchodilator drugs may be withheld 2 days before the test. c. The patient will breathe through the mouth and wear a nose clip during the test. d. The patient will be expected to walk on a treadmill during the test.

c. The patient will breathe through the mouth and wear a nose clip during the test.

In the older adult with chronic pulmonary disease, there is a loss of elastic recoiling of the lung and decreased chest wall compliance. What is the result of this occurrence? a. The thoracic area becomes shorter. b. The patient has an increased activity tolerance. c. There is an increase in anteroposterior ratio. d. The patient has severe shortness of breath.

c. There is an increase in anteroposterior ratio.

The nurse is assessing a patient's respiratory system. On auscultation the nurse hears squeaky, musical continuous sounds when the patient inhales and exhales. The nurse recognizes that these sounds are which abnormal finding? a. Fine crackles b. Coarse crackles c. Wheezes d. Rhonchi

c. Wheezes

The health care provider has prescribed varenicline for the patient who wishes to quit smoking. What specific priority teaching must the nurse provide for the patient and his family? a. Avoid spending time in enclosed spaces with active smokers. b. Make a list of all the reasons that you wish to quit smoking cigarettes. c. Plan to reward yourself with the money you save from not smoking cigarettes. d. Be sure to report any changes in behavior or thought processes to your health care provider.

d. Be sure to report any changes in behavior or thought processes to your health care provider.

Which assessment finding is an objective sign of chronic oxygen deprivation? a. Continuous cough productive of clear sputum b. Audible inspiratory and expiratory wheeze c. Chest pain that increases with deep inspiration d. Clubbing of fingernails and a barrel-shaped chest

d. Clubbing of fingernails and a barrel-shaped chest

Which assessment finding reflects an immediate gas exchange and perfusion problem? a. Clubbed fingers b. Barrel chest c. Weight loss d. Cyanosis

d. Cyanosis

What is a pulse oximeter used to measure? a. Oxygen perfusion in the extremities b. Pulse and perfusion in the extremities c. Generalized tissue perfusion d. Hemoglobin saturation with oxygen

d. Hemoglobin saturation with oxygen

Which airway structure is part of the immune system? a. Eustachian tubes b Turbinates c. Paranasal sinuses d. Palatine tonsils

d. Palatine tonsils

A patient returns to the unit after bronchoscopy. In addition to respiratory status assessment, which assessment does the nurse make in order to prevent aspiration? a. Presence of pain or soreness in throat b. Time and amount of last oral fluid intake c. Type and location of chest pain d. Presence or absence of gag reflex

d. Presence or absence of gag reflex

The nurse is caring for several patients who had diagnostic testing for respiratory disorders. Which diagnostic test has the highest risk for the postprocedural complication of pneumothorax? a. Bronchoscopy b. Laryngoscopy c. Computed tomography of lungs d. Thoracentesis

d. Thoracentesis

Tissue oxygen delivery through dissociation from hemoglobin is based on which factor? a. Saturation b. Oxygen tension c. Unloading from hemoglobin d. Tissues' need for oxygen

d. Tissues' need for oxygen

A patient who had neck surgery for removal of a tumor reports "not being able to breathe very well." The nurse observes that the patient has decreased chest movement and an elevated pulse. A bronchoscopy is ordered. For what reason did the provider order a bronchoscopy for this patient? a. Reverse and relieve any obstruction caused during the neck surgery. b. Assess the function of vocal cords or remove foreign bodies from the larynx. c. Aspirate pleural fluid or air from the pleural space. d. Visualize the larynx (airway structures) to use as a guide for intubation.

d. Visualize the larynx (airway structures) to use as a guide for intubation.