More respiratory

What are wheezes?

Lungs are clamping down (asthma), narrowed pathway where air is trying to get through • moisture or debris in larger airway; louder than crackles; inspiratory: Reactive Airway Disease, Asthma

Cheyne-Stokes respirations:

irregular shallow, deep, apnea> dying> function autonomic, air is not getting to brain

Pleural Friction Rub

low grating noise in peripheral and lateral chest; cough does not clear, noticed on inspiration/expiration: Plurisy • Velcro type rub • You will hear on inspiration and exhalation o Coughing hurts o May hear all over

Sarah is caring for 73 yo patient with COPD and he doesn't't understand why he is losing weight because he eats a lot? Best response?

o COPD burns a lot of calories because it takes a lot of energy to breath

While assessing the thoracic area of an adult client, the nurse plans to auscultate for voice sounds. To assess bronchophony, the nurse should ask the client to

repeat the phrase "ninety-nine."

A nurse is assessing a client with acute asthma. Which adventitious breath sound should the nurse expect to hear in this client?

Sibilant wheezes heard primarily during EXPIRATION but may also be heard on inspiration

An adult client has been diagnosed with bronchitis. What would the nurse most likely hear on auscultation?

Sonorous wheezes

Kusmaul

Trying to blow air off

The nurse notes that crepitus of the thorax has been documented. The nurse validates crepitus with which finding?

Crackling sensation on the surface of the chest wall upon palpation

Who should not be vaccinated for the flu?

Immunosuppressed cannot have LIVE vaccines-- flu mist

BIOTS breathing

Deep breath, Deep Breath, Apnea, Deep Breath, Deep Breath

A 68-year-old retired postman presents to the clinic with dull intermittent left-sided chest pain over the last few weeks. The pain occurs after he mows his lawn or chops wood. He says that the pain radiates to the left side of his jaw but nowhere else. He has felt light-headed and nauseated with the pain but has had no other symptoms. He states when he sits down for several minutes the pain goes away. Ibuprofen, Tylenol, and antacids have not improved his symptoms. He reports no recent weight gain, weight loss, fever, or night sweats. He has a past medical history of high blood pressure and arthritis. He quit smoking 10 years ago after smoking one pack a day for 40 years. He denies any recent alcohol use and no drug use. He is married with two healthy children. His mother died of breast cancer, and his father died of a stroke. His younger brother has had bypass surgery. Examination finds the client healthy appearing and breathing comfortably. His blood pressure is 140/90, and he has a pulse of 80. His head, eyes, ears, nose, and throat examinations are unremarkable. His lungs have normal breath sounds, and there are no abnormalities with percussion and palpation of the chest. His heart has a normal S1 and S2 and no S3 or S4. Further workup is pending. Which disorder of the chest best describes these symptoms?

Angina Pectoris

On auscultation of her chest, there is decreased air movement and a high-pitched whistling on expiration in all lobes. Percussion reveals resonant lungs. Which disorder of the thorax or lung does this presentation best describe?

Asthma

When crackles, wheezes, or rhonchi CLEAR WITH COUGH, which of the following is a likely etiology?

Bronchitis

Which of the following statements relating to assessment of the lungs and thorax is most accurate?

Bronchitis is characterized by excess mucus production and chronic cough.

A client experiences increasing DIFFICULTY TAKING IN A DEEP BREATH For which health problem should the nurse focus when assessing this client?

Chronic Obstructive Lung disease

During the lung assessment for a client with pneumonia, the nurse auscultates low-pitched bubbling, moist sounds that persists from early inspiration to early expiration. How should the nurse document these sounds?

Coarse crackles

A client comes to the clinic and states, "I have a bad cold and am having trouble breathing." The nurse checks the client's breath sounds and hears bilateral fine crackles at the base. Of what is this finding indicative?

Fluid in the alveoli

In planning for care for a client with asthma, the nurse included which nursing diagnosis?

Impaired gas exchange related to increased airway resistance

A nurse auscultates a client's lungs and hears fine crackles. What is an appropriate action by the nurse?

Instruct the client to cough forcefully

Which subjective finding in a client with tuberculosis should a nurse recognize as an indication of the onset of pleurisy?

Knife-like pain that worsens on inspiration

Stridor indicates what?

Laryngeal obstruction

A high pitched crowning sound from the UPPER AIRWAYS results from tracheal or laryngeal spasm and is called what?

Stridor

What is the term called for high pitched sound on inspiration and expiration?

Stridor

A patient has a nursing diagnosis of ineffective airway clearance. What intervention would be most appropriate?

Teach deep breathing and coughing.

The nurse assesses an adult client and observes that the client's breathing pattern is very labored and noisy, with occasional coughing. The nurse should refer the client to a physician for possible

chronic bronchitis.

Rhonchi

gook/obstruction in the big airways; like snoring or clearing mucous • Usually clears with cough; low pitch gurgling