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A child is admitted to the pediatric division with an acute asthma attack. The nurse assesses the lung sounds and respiratory rate. The mother asks the nurse, "Why is his chest sucking in above his stomach? The nurse's most accurate response is:
"He is using his chest muscles to help him breathe."
The nurse provides teaching to a client about oxygen safety. Which statement by the client about oxygen safety indicates an understanding of the teaching?
"I will contact the local fire department to let them know I have oxygen in use at my home."
The nurse is preparing discharge teaching for a client with a history of recurrent pneumonia. What deep breathing techniques will the nurse plan to teach?
"Take in as much air as possible, hold your breath briefly, and exhale slowly."
A nurse is delivering 3 L/min oxygen to a client via nasal cannula. What percentage of delivered oxygen is the client receiving?
32%
A nurse interviewing a pt. who says he has a dry, irritating cough that is not "bringing anything up" should ask whether he is taking ______________
ACE inhibitors
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
Your client is scheduled for a bronchoscopy to visualize the larynx, trachea, and bronchi. What precautions would you recommend to the client before the procedure?
Abstain from food for at least 6 hours before the procedure.
The nurse is caring for a client with recurrent hemoptysis who has undergone a bronchoscopy. Immediately following the procedure, the nurse should complete which action?
Assess the client for a cough reflex.
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
The nurse is assessing a client with lung cancer. What manifestations may suggest that the client has chronic hypoxia?
Clubbing
A nurse is assessing the breath sounds of a newborn. Which sound is an expected finding for this developmental level?
Crackles
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
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 caring for a client with COPD. What is an expected finding upon assessment?
Dyspnea
Which dietary guideline would be appropriate for the older adult homebound client with advanced respiratory disease who informs the nurse that she has no energy to eat?
Eat smaller meals that are high in protein.
Which skin disorder is associated with asthma?
Eczema
A nurse is percussing the thorax of a client with chronic emphysema. What percussion sound would most likely be assessed?
Hyperresonance Rationale: Hyperresonance is a loud, low, booming sound typically heard with percussion over emphysematous (excessively air-filled) lungs.
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 client has an increased anteroposterior chest diameter, dyspnea, and nasal flaring. The most appropriate nursing diagnosis is:
Ineffective Breathing Pattern related to hyperventilation related to increased anteroposterior diameter.
A health care provider orders the collection of a sputum specimen from a client with a suspected bacterial infection. Which action best ensures a usable specimen?
Instruct the client to inhale deeply and then cough.
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 client with a history of chronic obstructive pulmonary disease (COPD) has been ordered oxygen at 3 L/min as needed for treatment of dyspnea. What delivery mode is most appropriate to this client's needs?
Nasal cannula
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 nurse conducts a health history for a client with chronic bronchitis. Which action does the nurse take first when the client begins to experience respiratory distress?
Place the client in a comfortable position, ensure an open airway and if oxygen is prescribed start administration
What is the action of codeine when used to treat a cough?
Suppressant
When inspecting a client's chest to assess respiratory status, the nurse should be aware of which normal finding?
The chest should be slightly convex with no sternal depression.
A nurse takes a client's pulse oximetry reading and finds that it is normal. What does this finding indicate?
The client's available hemoglobin is adequately saturated with oxygen.
The nurse is caring for a client with chronic lung disease who is receiving oxygen by nasal cannula. Which action does the nurse perform correctly?
The nurse encourages the client to breathe through the nose with mouth closed.
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
The nurse is caring for a client with a decrease in airway diameter causing airway resistance. The client experiences coughing and mucus production. Upon lung assessment, which adventitious breath sounds are anticipated?
Wheezes
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
The nurse auscultates the lungs of a client with asthma who reports shortness of breath, sore throat, and congestion. Which finding does the nurse expect to document?
Wheezing
In which client would the nurse assess for a depressed respiratory system?
a client taking opioids for cancer pain
A nurse is preparing a client with a pleural effusion for a thoracentesis. The nurse should:
assist the client to a sitting position on the edge of the bed, leaning over the bedside table.
The nurse is caring for a postoperative adult client who has developed pneumonia. The nurse should assess the client frequently for symptoms of:
atelectasis
Upon evaluation of a client's medical history, the nurse recognizes that which condition may lead to an inadequate supply of oxygen to the tissues of the body?
chronic anemia
A client has edema of the feet and ankles, along with crackles in the lower lobes and a frothy, productive cough. The client is suffering from:
congestive heart failure
A woman comes to the emergency room with her 2-year-old son. She states he woke up and had a loud barking cough. The child is suffering from:
croup
Mr. Parks has chronic obstructive pulmonary disease (COPD). His nurse has taught him pursed-lip breathing, which helps him in which of the following ways?
decreases the amount of air trapping and resistance
Oxygen and carbon dioxide move between the alveoli and the blood by:
diffusion
The nurse is caring for a client who has been prescribed humidified oxygen at 6 L/minute. Which type of liquid will the nurse gather to set up the humidifier?
distilled water
A client is being seen in the pediatric clinic for a middle ear infection. The client's mother reports that when the client develops an upper respiratory infection, an ear infection seems quick to follow. What contributes to this event?
eustachian tubes
The nurse is caring for a client with facial burns who also is prescribed oxygen. What delivery device will the nurse select that is most appropriate for this client?
face tent
A client has been put on oxygen therapy because of low oxygen saturation levels in the blood. What should the nurse use to regulate the amount of oxygen delivered to the client?
flow meter
An older adult client is visibly pale with a respiratory rate of 30 breaths per minute. Upon questioning, the client states to the nurse, "I can't seem to catch my breath." The nurse has responded by repositioning the client and measuring the client's oxygen saturation using pulse oximetry, yielding a reading of 90%. The nurse should interpret this oxygen saturation reading in light of the client's:
hemoglobin level
The nurse is caring for a client who is diagnosed with Impaired Gas Exchange. While performing a physical assessment of the client, which data is the nurse likely to find, keeping in mind the client's diagnosis?
high respiratory rate
To drain the apical sections of the upper lobes of the lungs, the nurse should place the client in which position?
high-Fowler's position
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.
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.
A nurse is caring for an asthmatic client who requires a low concentration of oxygen. Which delivery device should the nurse use in order to administer oxygen to the client?
nasal cannula
Which is a sign of dyspnea specific to infants?
nasal flaring
A nurse is caring for a client who has spontaneous respirations and needs to have oxygen administered at a FiO2 of 100%. Which oxygen delivery system should the nurse use?
nonrebreather mask
While examining a client, the nurse palpates the client's chest and back. What would the nurse expect to identify with this technique?
pattern of thoracic expansion
A client returns to the telemetry unit after an operative procedure. Which diagnostic test will the nurse perform to monitor the effectiveness of the oxygen therapy ordered for the client?
pulse oximetry
What structural changes to the respiratory system should a nurse observe when caring for older adults?
respiratory muscles become weaker
A 55-year-old obese man reports excessive daytime sleepiness, morning headaches, and sore throat. His wife states that he snores a lot. Which disease is this client most likely suffering from?
sleep apnea
The term for the volume of air inhaled and exhaled with each breath is
tidal volume.
Which hollow tube transports air from the laryngeal pharynx to the bronchi?
trachea
High pitched musical sound =
wheeze
The home care nurse is visiting a client who is totally oxygen dependent and using home oxygen. Upon noticing a gas stove in the kitchen, what teaching will the nurse provide?
"An electric stove may be a safer choice for you."
The nurse is preparing discharge teaching for a client who has chronic obstructive pulmonary disease (COPD). Which teaching about deep breathing will the nurse include?
"Inhale slowly over three seconds, purse your lips, contract abdominal muscles, and exhale slowly."
You are the hospice nurse caring for a client with pulmonary fibrosis who wants to die at home. The client is having difficulty breathing. The family asks why it is so hard for the client to breathe. What would be the nurse's best response?
"The fibrosis of the lungs makes the lungs stiff, which makes it harder to breathe.
A client with a nonhealing pressure injury has been prescribed hyperbaric oxygen therapy (HBOT). The client tells the nurse, "This kind of treatment doesn't make any sense to me." What is the appropriate nursing response?
"Wounds heal because HBOT helps to regenerate new tissue quickly."
A client with a respiratory condition is receiving oxygen therapy. While assessing the client's PaO2, the nurse knows that the therapy has been effective based on which of the following readings?
84 mm Hg
The nurse schedules a pulmonary function test to measure the amount of air left in a client's lungs at maximal expiration. What test does the nurse order?
Residual Volume (RV)
The nurse is caring for a neonate with respiratory distress. Which sign appears early for the neonate with respiratory distress syndrome?
Tachypnea more than 60 breaths/min
Which term refers to the volume of air inhaled or exhaled during each respiratory cycle?
Tidal volume
A nurse is admitting a 6-year-old child after a tonsillectomy to the surgical unit. The nurse obtains the client's weight and places electrocardiogram (EKG) leads on the chest and a pulse oximeter on the left finger. The client's heart rate reads 100 bpm and the pulse oximeter reads 99%. These readings best indicate:
adequate tissue perfusion
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
The nurse is caring for a client receiving oxygen by nasal cannula at 2 L/min. Which oxygenation percentage concentration does the nurse anticipate will be delivered to the client?
24-28%
A nurse assessing a client's respiratory effort notes that the client's breaths are shallow and 8 per minute. Shortly after, the client's respirations cease. Which form of oxygen delivery should the nurse use for this client?
Ambu bag
The nurse is caring for a client who has a compromised cardiopulmonary system and needs to assess the client's tissue oxygenation. The nurse would use which appropriate method to assess this client's oxygenation?
Arterial blood gas
A client who was prescribed CPAP reports nonadherence to treatment. What is the priority nursing intervention?
Ask the client what factors contribute to nonadherence
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
The nurse is caring for a client receiving oxygen therapy via nasal cannula. The client suddenly becomes cyanotic with a pulse oximetry reading of 91%. What is the next most appropriate action the nurse should take?
Assess oxygen tubing connection
The nurse is performing a respiratory assessment on an infant. Which technique will the nurse use to obtain an accurate resp rate?
Assess respirations while the infant is being held by the parent
The nurse completes a focused respiratory assessment on an adult client. Which abnormal assessment data will the nurse document in the electronic health record?
Asymmetric chest expansion Intercostal retractions Dyspnea
A client is receiving supplemental oxygen. When determining the effectiveness of oxygen therapy, which arterial blood gas value is most important?
Partial pressure of arterial oxygen (PaO2)
The nurse is caring for an older adult client on home oxygen who has dentures but has quit wearing them stating that the dentures irritate the gums. What nursing action is appropriate?
Check the fit of the oxygen mask.
What finding by the nurse may indicate that the client has chronic hypoxia?
Clubbing of the fingers
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.
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 home care nurse visits a client who has dyspnea. The nurse notes the client has pitting edema in his feet and ankles. Which additional assessment would the nurse expect to observe?
Crackles in the 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
The nurse working on a gerontology unit admits a 77-year-old with recent shortness of breath. The nurse knows that the amount of respiratory dead space increases with age. What do these changes result in?
Decreased diffusion capacity for oxygen
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
The nurse provides care for the client with chronic obstructive pulmonary disease experiencing hypoxia. Which assessment prompts the nurse to immediately report findings to the health care provider?
Decreased level of consciousness
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
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
A patient is being educated in the use of incentive spirometry prior to having a surgical procedure. What should the nurse be sure to include in the education?
Encourage the patient to take approximately 10 breaths per hour, while awake.
The client is experiencing respiratory distress and the nurse places the client in a high Fowler position. Which action does the nurse take next?
Ensure airway patency
The nurse assesses a client and detects the following findings: difficulty breathing, increased respiratory and pulse rates, and pale skin with regions of cyanosis. What condition would the nurse suspect as causing these respiratory alterations?
Hypoxia
Which teaching about a flowmeter is important for the nurse to provide to a client using oxygen?
It regulates the amount of oxygen received.
A patient diagnosed with diabetic ketoacidosis would be expected to have which type of respiratory pattern?
Kussmaul respirations
The nurse is obtaining a pulse oximetry reading for a client admitted with exacerbation of chronic obstructive pulmonary disease (COPD). When observing a reading of 89%, what action should the nurse perform?
No action is required, because this may be normal for the client
Upon palpation of the sinus area, what would the nurse identify as a normal finding?
No sensation during palpation
The student nurse is learning breath sounds while listening to a client in the physician's office. An experienced nurse is assisting and notes air movement over the trachea to the upper lungs. The air movement is noted equally on inspiration as expiration. Which breath sounds would the nurse document?
Normal bronchovesicular sounds
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 a nurse observes that an older client's skin is dry and shiny and his nails are thickened, the nurse determines that the client is most likely experiencing
Poor tissue perfusion
What is the primary function of the larynx?
Producing sound
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
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
In relation to the structure of the larynx, which describes the cricoid cartilage?
The only complete cartilaginous ring in the larynx
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 with COPD who is prescribed a precise oxygen concentration. Which oxygen delivery system will the nurse select as the best option for the client?
Venturi mask
During data collection, the nurse auscultates low-pitched, soft sounds over the lungs' peripheral fields. Which appropriate terminology would the nurse use to describe these lung sounds when documenting?
Vesicular
