chapter 19: introduction to the respiratory system Med surg(106)

A nurse understands that a safe but low level of oxygen saturation provides for adequate tissue saturation while allowing no reserve for situations that threaten ventilation. What is a safe but low oxygen saturation level for a patient?

95%

The nurse is discussing activity management with a client who is postoperative following thoracotomy. What instructions should the nurse give to the client regarding activity immediately following discharge?

Perform shoulder exercises five times daily.

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

The nurse has assessed a client's family history for three generations. The presence of which respiratory disease would justify this type of assessment?

Asthma

The nurse assesses a patient with a heart rate of 42 and a blood pressure of 70/46. What type of hypoxia does the nurse determine this patient is displaying?

Circulatory hypoxia

The nurse is preparing to discharge a client after thoracotomy. The client is going home on oxygen therapy and requires wound care. As a result, the client will receive home care nursing. Which information should the nurse include in discharge teaching for this client?

Correct and safe use of oxygen therapy equipment

The nurse is assessing a patient in respiratory failure. What finding is a late indicator of hypoxia?

Cyanosis

A gerontologic nurse is analyzing the data from a client's focused respiratory assessment. The nurse is aware that the amount of respiratory dead space increases with age. What is the effect of this physiologic change?

Decreased diffusion capacity for oxygen

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.

The nurse is assessing a client who has a chest tube in place for the treatment of a pneumothorax. The nurse observes that the water level in the water seal rises and falls in rhythm with the client's respirations. How should the nurse best respond to this assessment finding?

Document that the chest drainage system is operating as it is intended.

A 68-year-old male patient has been admitted to the surgical unit from the PACU after surgical repair of an inguinal hernia. When performing the patient's admission assessment, the nurse notes that the patient has a barrel chest. This assessment finding should suggest to the nurse that the patient may have a history of what health problem?

Emphysema

The nurse is caring for a client with a lower respiratory tract infection. When planning a focused respiratory assessment, the nurse should know that this type of infection most often causes which type of impairment?

Impaired gas exchange

A client is scheduled to have excess pleural fluid aspirated with a needle to relieve dyspnea. The client inquires about the normal function of pleural fluid. What should the nurse describe?

It lubricates the movement of the thorax and lungs.

A nurse has performed tracheal suctioning on a client who experienced increasing dyspnea prior to a procedure. When applying the nursing process, how can the nurse best evaluate the outcomes of this intervention?

Measure the client's oxygen saturation.

A nurse practitioner diagnosed a patient with an infection in the maxillary sinuses. Select the area that the nurse palpated to make that diagnosis.

On the cheeks below the eyes

The nurse is admitting a patient with COPD. The decrease of what substance in the blood gas analysis would indicate to the nurse that the patient is experiencing hypoxemia?

PaO2

What is the primary function of the larynx?

Producing sound

The nurse is caring for a client who has a pleural effusion and who underwent a thoracoscopic procedure earlier in the morning. The nurse should prioritize assessment for which of the following?

Shortness of breath

In which position should the client be placed for a thoracentesis?

Sitting on the edge of the bed

The nurse is caring for a client who is to undergo a thoracentesis. In preparation for the procedure, the nurse places the client in which position?

Sitting on the edge of the bed

The critical care nurse and the other members of the care team are assessing the client to see if the client is ready to be weaned from the ventilator. What are the most important predictors of successful weaning that the nurse should identify?

Stable vital signs and arterial blood gases (ABGs)

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

Swallow reflex

An client is described as having pectus carinatum. What would be the physical manifestation of this condition?

The sternum protrudes and the ribs are sloped backward.

While assessing the client, the nurse observes constant bubbling in the water-seal chamber of the client's closed chest-drainage system. Which conclusion should the nurse reach?

The system has an air leak.

A client with chronic lung disease is undergoing lung function testing. What test result denotes the volume of air inspired and expired with a normal breath?

Tidal volume

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

Tidal volume

A client is being mechanically ventilated with an oral endotracheal tube in place. The nurse observes that the cuff pressure is 28 mm Hg. The nurse is aware of what complications that can be caused by this pressure? Select all that apply.

Tracheal ischemia Tracheal bleeding Pressure necrosis

A nurse is assessing a client's respiratory system. Which alveolar cells secrete surfactant to reduce lung surface tension?

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?

Type II cells

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.

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.

The amount of air inspired and expired with each breath is called:

tidal volume.

A client is having the tonsils removed. The client asks the nurse what function the tonsils normally serve. Which of the following would be the most accurate response?

"The tonsils help to guard the body from invasion of organisms."

The nurse notes that a client has several normal breaths that are followed by apnea that varies in length. The nurse knows that this breathing pattern is also known as?

Biot respirations

Following a chest X-ray, a patient has been diagnosed with a pleural effusion. The care team has concluded that the quantity of fluid in the patient's intrapleural space necessitates thoracentesis. What patient education should the nurse provide in anticipation of this procedure?

"It's very important that you remain still while the doctor is performing the procedure."

The nurse is preparing to perform tracheostomy care for a client with a newly inserted tracheostomy tube. Which action, if performed by the nurse, indicates the need for further review of the procedure?

Places clean tracheostomy ties then removes soiled ties after the new ties are in place without a second nurse assisting

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?

Ventilation exceeds perfusion.