Chapter 20
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?
"Conditions such as chronic bronchitis cause thickening of the bronchial mucosa so it makes it harder to breathe."
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 gag reflex -Increased presence of collagen in alveolar walls -Decreased presence of mucus
When assessing a client, which adaptation indicates the presence of respiratory distress?
Orthopnea
Upon palpation of the sinus area, what would the nurse identify as a normal finding?
No tenderness during palpation
What is the primary function of the larynx?
Producing sound
The nurse is admitting a client who just had a bronchoscopy. Which assessment should be the nurse's priority?
Swallow reflex
A client arrives at the physician's office stating 2 days of febrile illness, dyspnea, and cough. Upon assisting the client into a gown, the nurse notes that the client's sternum is depressed, especially on inspiration. Crackles are noted in the bases of the lung fields. Based on inspection, which will the nurse document?
the client has funnel chest
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?
Diagnosis of peripheral vascular disease
What finding by the nurse may indicate that the client has chronic hypoxia?
Clubbing of the fingers
The term for the volume of air inhaled and exhaled with each breath is
Tidal volume
A client arrived in the emergency department with a sharp object penetrating the diaphragm. When planning nursing care, which nursing diagnosis would the nurse identify as a priority?
Impaired gas exchange
A client has suspected fluid accumulation in the pleural space of the lungs and is scheduled for a thoracentesis. The nurse will implement which of the following for this procedure? Select all that apply.
-Educate the client about the need to cleanse the thoracic area. -Apply pressure to the puncture site after the procedure. -Complete a respiratory assessment after the procedure.
A nurse is performing a physical assessment on a client who has a history of a respiratory infection. Which documentation, completed by the nurse, indicates the resolution of the infection? Select all that apply
-Lung fields documented as clear in the bases. -Palpable vibrations over the chest wall when the client speaks. -Decreased fremitus when the client speaks "99." -Bronchovesicular sounds heard over the upper lung fields.
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 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?
Absent distal pulses
Which is a true statement regarding air pressure variances?
Air is drawn through the trachea and bronchi into the alveoli during inspiration.
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
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 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?
Bilateral lower lobes
In a patient diagnosed with increased intracranial pressure (IICP), the nurse would expect to observe which of the following respiratory rate or depth?
Bradypnea
The nurse auscultates crackles in a patient with a respiratory disorder. With what disorder would crackles be commonly heard?
Collapsed alveoli
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
The nurse is assessing a patient in respiratory failure. What finding is a late indicator of hypoxia?
Cyanosis
For air to enter the lungs (process of ventilation), the intrapulmonary pressure must be less than atmospheric pressure so air can be pulled inward. Select the movement of respiratory muscles that makes this happen during inspiration.
Diaphragm contracts and elongates the chest cavity.
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.
High or increased compliance occurs in which disease process?
Emphysema
Which respiratory volume is the maximum volume of air that can be inhaled after a normal exhalation?
Inspiratory reserve volume
A new nurse auscultates adventitious breath sounds but is not sure what to document and confers with an experienced nurse. This experienced nurse documents a pleural friction rub. Which of the following did the experienced nurse do during her assessment to identify the rub?
Instructed the client to hold the breath
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
A patient diagnosed with diabetic ketoacidosis would be expected to have which type of respiratory pattern?
Kussmaul respirations
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
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 clinical finding of pink, frothy sputum may be an indication of which condition?
Pulmonary edema
The client has just had an invasive procedure to assess the respiratory system. What does the nurse know should be assessed on this client?
Respiratory distress
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 nurse is admitting a client who just had a bronchoscopy. Which assessment should be the nurse's priority?
Swallow Reflex
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 clients 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
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?
They can be heard during inspiration and expiration
A nurse is assessing a client's respiratory system. Which alveolar cells secrete surfactant to reduce lung surface tension?
Type II
A nurse assesses a client's respiratory status. Which observation indicates that the client is having difficulty breathing?
Use of accessory muscle
What is the difference between respiration and ventilation?
Ventilation is the movement of air in and out of the respiratory tract.
What is the purpose of the vascular and ciliated mucous lining of the nasal cavities?
Warm and humidify inspired air
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 auscultated a patient's middle lobe of the lungs for abnormal breath sounds. To do this, the nurse placed the stethoscope on the:
Anterior surface of the right side of the chest, between the fourth and fifth rib.
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
The nurse is caring for a client diagnosed with pneumonia. The nurse assesses the client for tactile fremitus by completing which action?
Asking the client to repeat "ninety-nine" as the nurse's hands move down the client's thorax
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 interviewing a patient who says he has a dry, irritating cough that is not "bringing anything up." What medication should the nurse question the patient about taking?
Angiotensin converting enzyme (ACE) inhibitors
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
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?
Dull
A nurse is instructing the client on the normal sensations that can occur when contrast medium is infused during pulmonary angiography. Which client statement demonstrates an understanding of the teaching?
I will feel warm and may have chest pain
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?
Lungs are clear on auscultation
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?
Rhonchi
A client with chronic bronchitis is admitted to the health facility. Auscultation of the lungs reveals low-pitched, rumbling sounds. Which term should the nurse document?
Rhonchi
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
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
It is important for the nurse to provide required information and appropriate explanations of diagnostic procedures to clients with respiratory disorders in order to
manage decreased energy levels
A black client with asthma seeks emergency care for acute respiratory distress. Because of this client's dark skin, the nurse should assess for cyanosis by inspecting the:
mucous membranes
