Chapter 17: Assessment of Respiratory Function PrepU

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

A client experiencing hypothermia 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.

A patient with sinus congestion points to a location on the inside of his eye as the area of pain. The nurse documents that the patient is complaining of pain in which sinus?

Ethmoid The ethmoidal sinuses are located between the eyes and behind the nose. Inflammation and swelling block drainage into the nose; eventually an infection results.

A nurse assesses a client with crackles. What medical condition should the nurse suspect? Select all that apply. -Asthma -Chronic bronchitis -A collapsed alveoli -Pulmonary fibrosis -Pneumothorax

-Asthma -Chronic bronchitis -A collapsed alveoli -Pulmonary fibrosis Crackles are discrete, non-continuous sounds that result from the delayed reopening of collapsed alveoli. Crackles may or may not be cleared by coughing. They reflect underlying inflammation or congestion and are often present in such conditions as pneumonia, bronchitis, heart failure, asthma, bronchiectasis, and pulmonary fibrosis. Crackles are usually heard on inspiration, but they may also be heard on expiration. A client with a pneumothorax will have absent breath sounds.

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 puncture at the radial artery ABGs determine the blood's pH, oxygen-carrying capacity, levels of oxygen, CO2, and bicarbonate ion. Blood gas samples are obtained through an arterial puncture at the radial, brachial, or femoral artery. A client also may have an indwelling arterial catheter from which arterial samples are obtained. Blood gas samples are not obtained from the pleural surfaces or trachea and bronchi.

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? Flushed feeling in the client Raised temperature in the affected limb Excessive capillary refill Absent distal pulses

Absent distal pulses When monitoring clients after a pulmonary angiography, nurses must notify the health care provider about diminished or absent distal pulses, cool skin temperature in the affected limb, and poor capillary refill. When the contrast medium is infused, the client will sense a warm, flushed feeling.

A nurse is performing a respiratory assessment on a client with pneumonia. She asks the client to say "ninety-nine" several times. Through her stethoscope, she hears the words clearly over his left lower lobe. What term should the nurse use to document this finding?

Bronchophony Bronchophony is an increased intensity and clarity of voice sounds heard over a bronchus surrounded by consolidated lung tissue. Over normal lung tissue, the words are unintelligible; however, over areas of tissue consolidation, such as with pneumonia, the words are clear because the tissue enhances the sounds. Tactile fremitus is the vibration felt when the client speaks while the nurse holds her hand against his chest. Crepitation is a crackling sound heard in certain diseases such as pneumonia. Egophony is an abnormal change in tone heard when the client speaks normally as the nurse auscultates his chest.

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

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

Impaired gas exchange Airflow is decreased with atelectasis, which is a bronchial obstruction from collapsed lung tissue. If there is an obstruction, there is limited or no gas exchange in this area. Impaired gas exchange is thus the most likely nursing diagnosis with atelectasis.

What would the instructor tell the students purulent fluid indicates?

Infection A small amount of fluid lies between the visceral and parietal pleurae. When excess fluid or air accumulates, the physician aspirates it from the pleural space by inserting a needle into the chest wall. This procedure, called thoracentesis, is performed with local anesthesia. Thoracentesis also may be used to obtain a sample of pleural fluid or a biopsy specimen from the pleural wall for diagnostic purposes such as a culture, sensitivity, or microscopic examination. Purulent fluid is the recommended diagnosis for infection. Serous fluid may be associated with cancer, inflammatory conditions, or heart failure.

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 During lung scans, a radioactive contrast medium is administered intravenously for the perfusion scan. Before the perfusion scan, nurses must assess the client to check for allergies to iodine. Laryngoscopy determines inflammation. Dysrhythmias and bleeding are possible complications of mediastinoscopy.

A patient diagnosed with diabetic ketoacidosis would be expected to have which type of respiratory pattern? Kussmaul respirations Biot's respirations Apnea Cheyne-Stokes

Kussmaul respirations Kussmaul respirations are seen in patients with diabetic ketoacidosis. In Cheyne-Stokes respiration, rate and depth increase, then decrease until apnea occurs. Biot's respiration is characterized by periods of normal breathing (3 to 4 breaths) followed by a varying period of apnea (usually 10 to 60 seconds).

A physician has ordered that a client with suspected lung cancer undergo magnetic resonance imaging (MRI). The nurse explains the benefits of this study to the client. What is the reason the client with suspected lung cancer would undergo magnetic resonance imaging (MRI)? Tumor densities can be seen with radiolucent images. Narrow-beam x-ray can scan successive lung layers. Lung blood flow can be viewed after a radiopaque agent is injected. MRI can view soft tissues and can help stage cancers.

MRI can view soft tissues and can help stage cancers. MRI uses magnetic fields and radiofrequency signals to produce a detailed diagnostic image. MRI can visualize soft tissues, characterize nodules, and help stage carcinomas. The other options describe different studies.

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

Orthopnea Orthopnea is the term used to describe a client's inability to breathe easily except in an upright position. Orthopnea may occur in clients with heart disease and, occasionally, in clients with COPD. Clients with orthopnea are placed in a high Fowler's position to facilitate breathing. Dyspnea refers to labored breathing or shortness of breath. Hemoptysis refers to expectoration of blood from the respiratory tract. Hypoxemia refers to low oxygen levels in the blood.

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 Lung infarction Bronchogenic carcinoma Bacterial pneumonia

Pleurisy Pleuritic pain from irritation of the parietal pleura is sharp and seems to "catch" on inspiration; patients often describe it as being "like the stabbing of a knife." In carcinoma, the pain may be dull and persistent because the cancer has invaded the chest wall, mediastinum, or spine.

The clinical finding of pink, frothy sputum may be an indication of which condition? An infection A lung abscess Pulmonary edema Bronchiectasis

Pulmonary edema Profuse frothy, pink material, often welling up into the throat, may indicate pulmonary edema. Foul-smelling sputum and bad breath may indicate a lung abscess, bronchiectasis, or an infection caused by fusospirochetal or other anaerobic organisms.

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? Bronchovesicular Venous hum Rales Rhonchi

Rhonchi Rhonchi or sonorous wheezes are deep, low-pitched, rumbling sounds heard usually on expiration. The etiology of rhonchi is associated with chronic bronchitis. Rales or crackles are soft, high-pitched sounds. A venous hum is a blood flow humming sound. Bronchovesicular sound is an intermediate pitch with expiration and inspiration.

The nurse is admitting a client who just had a bronchoscopy. Which assessment should be the nurse's priority?

Swallow reflex The physician sprays a local anesthetic into the client's throat before performing a bronchoscopy. The nurse must assess the swallow reflex when the client returns to the unit and before giving him anything by mouth. The nurse should also assess for medication allergies, carotid pulse, and deep breathing, but they aren't the priority at this time.

The nurse receives an order to obtain a sputum sample from a client with hemoptysis. When advising the client of the physician's order, the client states not being able to produce sputum. Which suggestion, offered by the nurse, is helpful in producing the sputum sample? Take deep breaths and cough forcefully. Use the secretions present in the oral cavity. Drink 8 oz of water to thin the secretions for expectoration. Tickle the back of the throat to produce the gag reflex.

Take deep breaths and cough forcefully. Taking deep breaths moves air around the sputum and coughing forcefully moves the sputum up the respiratory tract. Once in the pharynx, the sputum can be expectorated into a specimen container. Producing a gag reflex elicits stomach contents and not respiratory sputum. Dilute and thinned secretions are not helpful in aiding expectoration. A sputum culture is not a component of oral secretions.

The volume of air inhaled and exhaled with each breath is termed Expiratory reserve volume Tidal volume Vital capacity Residual volume

Tidal volume Tidal volume is the volume of air inhaled and exhaled with each breath. Residual volume is the volume of air remaining in the lungs after a maximum expiration. Vital capacity is the maximum volume of air exhaled from the point of maximum inspiration. Expiratory reserve volume is the maximum volume of air that can be exhaled after a normal inhalation.

Which term refers to the volume of air inhaled or exhaled during each respiratory cycle?

Tidal volume Tidal volume refers to the volume of air inhaled or exhaled during each respiratory cycle when breathing normally. Normal tidal volume ranges from 400 to 700 ml. Vital capacity refers to the total volume of air that can be exhaled during a slow, maximal expiration after maximal inspiration. Functional residual capacity refers to the volume of air remaining in the lungs after a normal expiration. Maximal voluntary ventilation is the greatest volume of air expired in 1 minute with maximal voluntary effort.

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

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

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

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

You are caring for a client admitted with chronic bronchitis. The client is having difficulty breathing, and the family asks you what causes this difficulty. What would be your best response? "Anytime there is a chronic disease process it is hard for the person to breathe." "Having a chronic respiratory disease scars the lung and affects the effort it takes to breathe." "In this particular case your family member is just overly tired and having problems breathing." "Conditions such as chronic bronchitis cause thickening of the bronchial mucosa so it makes it harder to breathe."

"Conditions such as chronic bronchitis cause thickening of the bronchial mucosa so it makes it harder to breathe." Conditions that may alter bronchial diameter and affect airway resistance include contraction of bronchial smooth muscle (e.g., asthma); thickening of bronchial mucosa (e.g., chronic bronchitis); airway obstruction by mucus, a tumor, or a foreign body; and loss of lung elasticity (e.g., emphysema). Option A is incorrect, not all chronic diseases make it hard to breathe. Option B is incorrect; not all chronic respiratory diseases caused scarring in the lung. Option C is incorrect; this response negates the families question and belittles their concern.

The nurse is caring for a client diagnosed with pneumonia. The nurse assesses the client for tactile fremitus by completing which action? Instructing the patient to take a deep breath and hold it while the diaphragm is percussed Placing the thumbs along the costal margin of the chest wall and instructing the patient to inhale deeply Asking the patient to say "one, two, three" while auscultating the lungs Asking the patient to repeat "ninety-nine" as the nurse's hands move down the patient's thorax

Asking the patient to repeat "ninety-nine" as the nurse's hands move down the patient's thorax While the nurse is assessing for tactile fremitus, the client is asked to repeat "ninety-nine" or "one, two, three," or "eee, eee, eee" as the nurse's hands move down the client's thorax. Vibrations are detected with the palmar surfaces of the fingers and hands, or the ulnar aspect of the extended hands, on the thorax. The hand(s) are moved in sequence down the thorax, and corresponding areas of the thorax are compared. Asking the client to say "one, two, three" while auscultating the lungs is not the proper technique to assess for tactile fremitus. The nurse assesses for anterior respiratory excursion by placing the thumbs along the costal margin of the chest wall and instructing the client to inhale deeply. The nurse assesses for diaphragmatic excursion by instructing the client to take a deep breath and hold it while the diaphragm is percussed.

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

Assess the patient for a cough reflex. After the bronchoscopy procedure, the client must take nothing by mouth until the cough reflex returns, because the preoperative sedation and local anesthesia impair the protective laryngeal reflex and swallowing. Once the client demonstrates a cough reflex, the nurse may offer ice chips and eventually fluids. The client is sedated during the procedure, not afterward. The client is not required to maintain bed rest following the procedure.

The nurse is caring for a client reporting chest discomfort. The client's diagnosis at admission is left lower lobe pneumonia. Which strategy will the nurse instruct the client to use to help alleviate the discomfort?

Assume a left side-lying position while in bed Pleuritic pain from irritation of the parietal pleura is sharp and seems to "catch" upon inspiration; clients often describe it as "like the stabbing of a knife." Clients are more comfortable when they lay on the affected side because this splints the chest wall, limits expansion and contraction of the lung, and reduces the friction between the injured or diseased pleurae on that side. Pain associated with cough may be reduced manually by splinting the rib cage. The nurse would instruct the client to lay on the left side, not the right, to decrease the pain. While pain medication may be administered, nonpharmacological therapies and nonnarcotic interventions should be implemented first. Deep breathing exercises would not help to decrease the pain, but would rather slow the client's breathing and expand the lungs.

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 Pneumothorax Acute respiratory obstruction Adult respiratory distress syndrome

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.

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? Posterior bronchioles Anterior bronchial tree Right lower lobe Bilateral lower lobes

Bilateral lower lobes Assessment of the anterior and posterior lungs is part of the nurse's routine evaluation. Fluid overload should be monitored for accumulation in the lungs. Dependent areas must be assessed for breath sounds. The bases of the lungs are considered dependent areas. Fluid in the lungs will usually produce the adventitious sounds of crackles, most frequently auscultated in the bilateral bases of the lungs.

What finding by the nurse may indicate that the client has chronic hypoxia? Cyanosis Peripheral edema Crackles Clubbing of the fingers

Clubbing of the fingers Clubbing of the fingers is a change in the normal nail bed. It appears as sponginess of the nail bed and loss of the nail bed angle. It is a sign of lung disease that is found in patients with chronic hypoxic conditions, chronic lung infections, or malignancies of the lung. Cyanosis can be a very late indicator of hypoxia, but it is Clubbing of the fingers a reliable sign of hypoxia. The other signs listed may represent only a temporary hypoxia.

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

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.

The nurse is caring for a client with extensive respiratory disease. Which is a late sign of hypoxia the client may experience? Cyanosis Confusion Dyspnea Restlessness

Cyanosis Cyanosis is a late sign of hypoxia. Hypoxia may cause restlessness and an initial rise in blood pressure that is followed by hypotension and somnolence.

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 Crackles Cyanosis Son's statement

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.

When the nurse is assessing the older adult patient, what gerontologic changes in the respiratory system should the nurse be aware of? (Select all that apply.) -Decreased alveolar duct diameter -Increased presence of mucus -Decreased gag reflex -Increased presence of collagen in alveolar walls -Decreased presence of mucus

Decreased gag reflex Increased presence of collagen in alveolar walls Decreased presence of mucus Age-related changes in the respiratory system include a decrease in mucus, decrease in gag reflex, increase in collagen in the alveolar walls of the lungs, and increase in alveolar duct diameter.

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 During the physical examination, the nurse must inspect and gently palpate the trachea to assess for placement and deviation from the midline. The nurse examines the posterior pharynx and tonsils with a tongue blade and light, and notes any evidence of swelling, inflammation, or exudate, as well as changes in color of the mucous membranes. The nurse also examines the anterior, posterior, and lateral chest walls for any evidence of muscle weakness.

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 The rectum The stomach The lungs The nose

The lungs Blood from the lung is usually bright red, frothy, and mixed with sputum. Initial symptoms include a tickling sensation in the throat, a salty taste, a burning or bubbling sensation in the chest, and perhaps chest pain, in which case the client tends to splint the bleeding side. This blood has an alkaline pH (>7.0). Blood from the stomach is vomited rather than expectorated, may be mixed with food, and is usually much darker; it is often referred to as "coffee ground emesis." This blood has an acidic pH (<<7.0). Bloody sputum from the nose or the nasopharynx is usually preceded by considerable sniffing, with blood possibly appearing in the nose.

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

Type II cells There are three types of alveolar cells. Type I and type II cells make up the alveolar epithelium. Type I cells account for 95% of the alveolar surface area and serve as a barrier between the air and the alveolar surface; type II cells account for only 5% of this area, but are responsible for producing type I cells and surfactant. Surfactant reduces surface tension, thereby improving overall lung function. Alveolar macrophages, the third type of alveolar cells, are phagocytic cells that ingest foreign matter and, as a result, provide an important defense mechanism. The epithelium of the alveoli does not contain Type IV cells.

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? There is an absence of perfusion and ventilation. Ventilation exceeds perfusion. Ventilation matches perfusion. Perfusion exceeds ventilation.

Ventilation exceeds perfusion A high ventilation-perfusion rate means that ventilation exceeds perfusion, causing dead space. The alveoli do not have an adequate blood supply for gas exchange to occur. This is characteristic of a variety of disorders, including pulmonary emboli, pulmonary infarction, and cardiogenic shock.

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? Rales Crackles Wheezes Rhonchi

Wheezes Sibilant wheezes are continuous, musical, high-pitched, whistle-like sounds heard during inspiration and expiration caused by air passing through narrowed or partially obstructed airways; they may clear with coughing. Crackles, formerly called rales, are soft, high-pitched, discontinuous popping sounds that occur during inspiration (while usually heard on inspiration, they may also be heard on expiration); they may or may not be cleared by coughing. Rhonchi, or sonorous wheezes, are deep, low-pitched rumbling sounds heard primarily during expiration; they are caused by air moving through narrowed tracheobronchial passages.

Understanding pulmonary physiology, what characteristic would the nurse expect to result in decreased gas exchange in older adults?

alveolar walls containing fewer capillaries Although the number of alveoli remains stable with age, the alveolar walls become thinner and contain fewer capillaries, resulting in decreased gas exchange. The lungs also lose elasticity and become stiffer. Elasticity of lungs does not increase with age, and the number of alveoli does not decrease with age.

The nurse auscultates the lung sounds of a client during a routine assessment. The sounds produced are harsh and cracking, sounding like two pieces of leather being rubbed together. The nurse would be correct in documenting this finding as

pleural friction rub A pleural friction rub is heard secondary to inflammation and loss of lubricating pleural fluid. Crackles are soft, high-pitched, discontinuous popping sounds that occur during inspiration. Sonorous wheezes are deep, low-pitched rumbling sounds heard primarily during expiration. Sibilant wheezes are continuous, musical, high-pitched, whistle-like sounds heard during inspiration and expiration.