Med Serge: Respiratory system #1

Rhonchi are coarse and moist sounds caused by (obstruction or rubbing of membrane) of the airway with thick mucus, and they usually clear or change with coughing as the mucus moves or is expectorated.

obstruction

At which interval are humidified oxygen systems replaced to prevent infection? a. 1 day b. 3 days

a. 1 day prevention of infection

Which finding would the nurse expect in a client with left-side phrenic nerve paralysis? a. Left base dullness to percussion b. Left lung expiratory wheezes

a. Left base dullness to percussion Because phrenic nerve paralysis limits diaphragmatic contraction and lung expansion on the left, the left base will be dull to percussion.

An abnormal indentation of the lower sternum above the xiphoid process a. pectus excavatum b. pectus carinatum

a. Pectus excavatum

Pectus carinatum is a. a prominent abnormal protrusion of the sternum. b. an abnormal indentation of the lower sternum above the xiphoid process.

a. a prominent abnormal protrusion of the sternum.

After a laryngectomy, a client experiences frequent coughing episodes and copious production of secretions. The nurse would explain that the symptoms are the result of which condition? a. the reaction of the mucous membranes to air that is dry and cool b. An upper respiratory inflammation caused by allergies

a. the reaction of the mucous membranes to air that is dry and cool Air is moisturized and warmed as it passes through the nasopharynx. With a laryngectomy this area is bypassed, and the tracheobronchial tree compensates by producing copious amounts of secretions.

Which procedure is correct a. A right upper lobectomy involves removal of only 3 lobes b. A pneumonectomy would describe removal of the entire right lung.

b. A pneumonectomy would describe removal of the entire right lung. A right upper lobectomy involves removal of only 1 lobe

Chronic hypoxemia causes pulmonary hypertension. y/n

yes

(Inspiratory wheezes or Expiratory wheezes) are a more ominous finding and indicate further progression of airway obstruction.

Inspiratory wheezes

A client is admitted to the hospital with a diagnosis of emphysema. When teaching the client about breathing exercises, the nurse would include which instruction? a. Perform diaphragmatic exercises to improve contraction of the diaphragm. b. Spend more time inhaling than exhaling to blow off carbon dioxide.

a. Perform diaphragmatic exercises to improve contraction of the diaphragm.

A client with obstructive airway disease experiences coughing spasms. Which suggestion would the nurse provide to help the client successfully manage this problem? a. Postpone the planned vacation to go snow skiing. b. Use aerosolized cleaning products when dusting.

a. Postpone the planned vacation to go snow skiing. Extreme temperature changes should be avoided, especially environmental heat or cold, because they promote bronchospasms.

When assessing the breath sounds of a client with chronic obstructive pulmonary disease (COPD), the nurse hears moist rumbling sounds that improve after the client coughs. How will the nurse document the lung sounds? a. Rhonchi b. Vesicular sounds

a. Rhonchi

Which action by a client with asthma indicates that the client teaching about use of a peak flow meter has been effective? a. Uses a quick relief inhaled medication when peak flow is in the yellow zone b. Stops taking the daily inhaled corticosteroid when peak flow is in the yellow zone

a. Uses a quick relief inhaled medication when peak flow is in the yellow zone

Which pathophysiological changes in the lungs occur with emphysema? Select all that apply. One, some, or all responses may be correct. a. collapse of alveolar walls b. trapping of air in distal lung structures c. increases in pulmonary artery pressures

a. collapse of alveolar walls b. trapping of air in distal lung structures c. increases in pulmonary artery pressures Destruction of alveolar walls in emphysema leads to alveolar wall collapse and trapping of air in distal lung structures, leading to poor gas exchange.

A client undergoes a laryngectomy and radical neck dissection. Two tubes from the area of the incision are connected to portable wound drainage systems. When edema in the client's neck is noted, the nurse would monitor for which indication of a postoperative complication? a. restlessness b. cloudy wound drainage

a. restlessness The client has a high risk for airway obstruction from the edema; restlessness and dyspnea indicate cerebral hypoxia.

Which finding in a client with asthma exacerbation requires the most rapid action by the nurse? a. Report of chest tightness b. Markedly decreased breath sounds

b. Markedly decreased breath sounds

High-pitched crackles are fine, short, interrupted popping sounds best heard on (inspiration or expiration) that occur with problems such as heart failure when air passes through fluid within the alveoli.

inspiration

Clients with asthma exacerbation frequently report chest tightness, but this finding does not indicate possible impending respiratory arrest. y/n

yes

Left-sided heart failure causes pulmonary congestion with fluid-filled alveoli. y/n

yes

Radiating anterior chest pain occurs with angina or a myocardial infarction. y/n

yes

1. Assess client's vital signs and lung sounds. 2.Activate the ventilator hyperoxygenation setting. 3.Insert the catheter without applying suction. 4.Rotate the catheter while suction is applied. or 1. Activate the ventilator hyperoxygenation setting. 2.Assess client's vital signs and lung sounds. 3.Insert the catheter without applying suction. 4.Rotate the catheter while suction is applied.

1. Assess client's vital signs and lung sounds. 2.Activate the ventilator hyperoxygenation setting. 3.Insert the catheter without applying suction. 4.Rotate the catheter while suction is applied.

After the nurse has taught a client about the use of a metered-dose inhaler with a spacer, which statement indicates the need for further teaching? a. I will shake the whole unit vigorously one or two times b. I will hold my breath for at least 10 seconds after each puff

a. I will shake the whole unit vigorously one or two times

A client who had thoracic surgery reports pain at the incision site when coughing and deep breathing. Which action would the nurse take? a. Instruct the client to splint the wound with a pillow when coughing. b. Assess the intensity of the pain and administer the prescribed analgesic.

a. Instruct the client to splint the wound with a pillow when coughing.

Emphysema a. a condition in which the air sacs of the lungs are damaged and enlarged, causing breathlessness. or b. a complete or partial collapse of the entire lung or area (lobe) of the lung.

a condition in which the air sacs of the lungs are damaged and enlarged, causing breathlessness. b. atelectasis

Stridor: a. a high-pitched, shrill, harsh sound caused by laryngeal obstruction and can be heard on auscultation over the upper airways or with the naked ear. b. continuous, low-pitched, coarse sounds often described as having a snoring or moaning quality that occur with partial bronchial obstruction caused by mucus, bronchospasm, foreign bodies, or tumors.

a high-pitched, shrill, harsh sound caused by laryngeal obstruction and can be heard on auscultation over the upper airways or with the naked ear.

The nurse is caring for clients on a medical-surgical unit and identifies that which client has the highest risk for developing a pulmonary embolism? a. An obese client with leg trauma b. a skinney client with diabetes has cellulitis

a. An obese client with leg trauma

Which finding by the nurse would be most important to report to the health care provider before a client undergoes a spiral computed tomography (CT) scan for possible pulmonary embolism? Select all that apply. One, some, or all responses may be correct. a. Client has poor skin turgor and dry oral mucosa. b. Client has rich skin turgor and moist oral mucosa.

a. Client has poor skin turgor and dry oral mucosa.

A minimum of a (1-minute gap or 3-minutes gap) should be given in between the puffs to ensure proper movement of the medications into the lungs.

1 minute gap

The client should hold his or her breath for at least 20 seconds so that the medication does not escape with exhalation. y/n

NO. 10 seconds

How would the nurse document client findings of abnormal respirations with alternating periods of apnea and rapid breathing? a. Cheyne-Stokes respirations b. Kussmaul breathing

Cheyne-Stokes respirations

The alveoli do not become filled with fluid in emphysema. y/n

yes

When a client has difficulty swallowing after a stroke, which action by the nurse would be most important in preventing pneumonia? a. Having suction available during meals b. Teaching about incentive spirometer use

a. Having suction available during meals

Which type of adventitious breath sound would the nurse expect when auscultating the posterior chest of a client with pleurisy who is reporting sharp chest pain with deep breathing? a. Pleural friction rub b. Rhonchi

a. Pleural friction rub Pleurisy is caused by inflammation of the pleural surfaces, and a frequent clinical manifestation is a pleural friction rub, which is a rough, scratching, grating, creaking sound caused by inflamed pleural surfaces rubbing together. It is frequently associated with chest pain.

Markedly decreased breath sounds may indicate very limited airflow and life-threatening asthma exacerbation. Nursing intervention: a. The nurse would immediately check oxygen saturation and anticipate the possible need for mechanical ventilation. b. The nurse would immediately turn off the light and lay him on his back to improve life-0threatening asthma exacerbation.

a. The nurse would immediately check oxygen saturation and anticipate the possible need for mechanical ventilation.

Which risk factor for head and neck cancer would the nurse assess for in a client with a persistent, nagging cough? Select all that apply. One, some, or all responses may be correct. a. Type of employment b. Presence of ear pain c. History of tobacco use d. Oral hygiene practices e. Amount of alcohol intake

a. Type of employment b. Presence of ear pain c. History of tobacco use d. Oral hygiene practices e. Amount of alcohol intake

When the nurse obtains a health history for a 50-year-old client with an 80 pack-year history of cigarette smoking and daily alcohol use, which finding is most important to report to the health care provider? a. Vocal hoarseness for several months b. Shortness of breath when walking quickly uphill

a. Vocal hoarseness for several months Persistent vocal hoarseness in a client with a history of cigarette smoking and alcohol use may indicate laryngeal cancer and requires rapid referral for further testing such as laryngoscopy and biopsy.

A firefighter is admitted to the emergency department with severe dermal and inhalation burns. On assessment, the nurse identifies tachycardia, tachypnea, and dyspnea. The nurse auscultates the client's lungs and expects to hear which type of breath sound? a. stridor b. rhonchi

a. stridor

A client is admitted to the intensive care unit with pulmonary edema. Which clinical finding would the nurse expect when performing the admission assessment? a. radiating anterior chest pain b crackles at bases of the lungs

b crackles at bases of the lungs Crackles are the sound of air passing through fluid in the alveolar spaces; in pulmonary edema, fluid moves from the intravascular compartment into the alveoli. Hypervolemia leads to pulmonary edema. The pulse is bounding with hypervolemia. The blood pressure usually is increased with hypervolemia.

Which client statement indicates that the nurse's preoperative teaching about right upper lobectomy has been effective? a. My entire right lung will be gone after this surgery." b. "I will have chest tubes to help with drainage after surgery."

b. "I will have chest tubes to help with drainage after surgery." Chest tubes are used to drain fluid from the pleural space and help with lung reexpansion after lobectomy.

A client has a leaking thoracic duct after a radical neck surgery. The nurse expects that the postoperative plan of care will include which prescriptions? a. A gastrostomy tube, a high-fat diet, and bed rest b. A chet tube, total parenteral nutrition (TPN), and bed rest

b. A chet tube, total parenteral nutrition (TPN), and bed rest A chest tube drains the leaking chyle from the thoracic area; TPN provides nutrition, boosts immune defenses, and decreases thoracic duct flow.

Which information about a client who is scheduled for magnetic resonance imaging (MRI) of the chest is most important to report to the health care provider before the procedure? a. Client has multiple facial and body piercings b. Client has surgical clips in place after craniotomy.

b. Client has surgical clips in place after craniotomy. Surgical clips are metal and may move slightly with MRI, causing bleeding into brain tissue. The health care provider would be notified and another diagnostic procedure would be used for this client.

A client who had a laryngectomy for cancer of the larynx is being transferred from the postanesthesia care unit to a surgical unit. Which is the most important equipment that the nurse would place in the client's room? a. suction supplies b. tracheostomy set

a. suction supplies

Which finding by the nurse who is caring for a client with a nasal fracture is most important to communicate to the health care provider? a. Ecchymosis under both eyes b. Dipstick testing of nasal drainage positive for glucose

b. Dipstick testing of nasal drainage positive for glucose Glucose in the nasal drainage indicates leakage of cerebrospinal fluid and possible skull fracture. The nurse will notify the health care provider and anticipate further diagnostic testing and treatment to prevent complications such as meningitis.