Chapter 20: Assessment of Respiratory Function

The nurse inspects the thorax of a patient with advanced emphysema. The nurse expects chest configuration changes consistent with a deformity known as

Barrel chest

Which of the following disease processes cause increased compliance?

Emphysema

A pediatrician diagnosed a child with swollen and inflamed adenoids. The nurse practitioner confirmed the diagnosis by

Inspecting the roof of the nasopharynx.

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.

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

No sensation during palpation

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.

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

A client experiencing hypothermia

A client appears to be breathing faster than during the last assessment. Which of the following interventions should the nurse perform?

Count the rate of respirations.

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

During a preadmission assessment, for what diagnosis would the nurse expect to find decreased tactile fremitus and hyperresonant percussion sounds?

Emphysema

A client with chronic bronchitis is admitted to the health facility. Auscultation of the lungs reveals low-pitched, rumbling sounds. Which of the following describes these sounds?

Rhonchi

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 client with a suspected pulmonary disorder undergoes pulmonary function tests. To interpret test results accurately, the nurse must be familiar with the terminology used to describe pulmonary functions. Which term refers to the volume of air inhaled or exhaled during each respiratory cycle?

Tidal volume

The instructor of the pre-nursing physiology class is explaining respiration to the class. What does the instructor explain is the main function of respiration?

To exchange oxygen and CO2 between the atmospheric air and the blood and between the blood and the cells

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

Which is a deformity of the chest that occurs as a result of overinflation of the lungs?

Barrel chest

High or increased compliance occurs in which disease process?

Emphysema

Which of the following is a noninvasive method of continuously monitoring the oxygen saturation of hemoglobin (SaO2)?

Pulse oximetry

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

Don't eat.

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

Swallow reflex

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."

The nurse is caring for a client with an exacerbation of COPD and scheduled for pulmonary function studies using a spirometer. Which client statement would the nurse clarify?

"I will breathe in through my mouth and out through my nose."

The nurse is instructing the client on the normal sensations, which can occur when contrast medium is infused during pulmonary angiography. Which statement, made by the client, demonstrates an understanding?

"I will feel warm and an urge to cough."

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 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 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

The nurse is caring for a patient with a pulmonary disorder. What observation by the nurse is indicative of a very late symptom of hypoxia?

Cyanosis

Lung compliance (the ability of the lungs to stretch) is a physical factor that affects ventilation. A nurse is aware that a patient who has lost elasticity in the lung tissue has a condition known as ...

Emphysema

While assessing for tactile fremitus, the nurse palpates almost no vibration. Which of the following conditions in this client's history will account for this finding?

Emphysema

The nurse is performing an assessment for a patient with congestive heart failure. The nurse asks if the patient has difficulty breathing in any position other than upright. What is the nurse referring to?

Orthopnea

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

Orthopnea

Which term is used to describe the inability to breathe easily except in an upright position?

Orthopnea

A student nurse is working with a client who is diagnosed with head trauma. The nurse has documented Cheyne-Stokes respirations. The student would expect to see which of the following?

Regular breathing where the rate and depth increase, then decrease.

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 a funnel chest.

What is the difference between respiration and ventilation?

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

The nursing instructor is teaching a pre-nursing pathophysiology class. The class is covering the respiratory system. The instructor explains that the respiratory system is comprised of both the upper and lower respiratory system. The nose is part of the upper respiratory system. The instructor continues to explain that the nasal cavities have a vascular and ciliated mucous lining. What is the purpose of the vascular and ciliated mucous lining of the nasal cavities?

Warm and humidify inspired air