Respiratory Exam
For which reason does gas exchange decrease in older adults?
The alveolar walls contain fewer capillaries. Although the number of alveoli remains stable with age, the alveolar walls become thinner and contain fewer capillaries, resulting in decreased gas exchange. The lungs also lose elasticity and become stiffer. Elasticity of lungs does not increase with age, and the number of alveoli does not decrease with age.
A nurse recognizes that a client with tuberculosis needs further teaching when the client states:
"The people I have contact with at work should be checked regularly." The client requires additional teaching if he states that coworkers need to be checked regularly. Such casual contacts needn't be tested for tuberculosis. However, a person in close contact with a person who's infectious is at risk and should be checked. The client demonstrates effective teaching if he states that he'll take his medications for 9 to 12 months, that coworkers don't need medication, and that he requires laboratory tests while on medication. Coworkers not needing medications, taking the medication for 9 to 12 months, and having scheduled laboratory tests are all appropriate statements.
A nurse is caring for a group of clients on a medical-surgical floor. Which client is at greatest risk for developing pneumonia?
A client with a nasogastric tube Nasogastric, orogastric, and endotracheal tubes increase the risk of pneumonia because of the risk of aspiration from improperly placed tubes. Frequent oral hygiene and checking tube placement help prevent aspiration and pneumonia. Although a client who smokes is at increased risk for pneumonia, the risk decreases if the client has stopped smoking. Ambulation helps prevent pneumonia. A client who receives opioids, not acetaminophen, has a risk of developing pneumonia because respiratory depression may occur.
A client has a sucking stab wound to the chest. Which action should the nurse take first?
Apply a dressing over the wound and tape it on three sides. The nurse should immediately apply a dressing over the stab wound and tape it on three sides to allow air to escape and to prevent tension pneumothorax (which is more life-threatening than an open chest wound). Only after covering and taping the wound should the nurse draw blood for laboratory tests, assist with chest tube insertion, and start an I.V. line.
Which statement is true about both lung transplant and bullectomy?
Both procedures improve the overall quality of life of a client with COPD. Treatments for COPD are aimed more at treating the symptoms and preventing complications, thereby improving the overall quality of life of a client with COPD. In fact, there is no cure for COPD. Lung transplant is aimed at treating end-stage emphysema and bullectomy is used to treat clients with bullous emphysema.
The nurse knows that there are three types of chronic pharyngitis. Which of the following is characterized by numerous swollen lymph follicles on the pharyngeal wall?
Chronic granular Chronic granular pharyngitis is characterized by numerous swollen lymph follicles on the pharyngeal wall. Aphonia refers to the inability to use one's voice. Atrophic pharyngitis is characterized by a membrane that is thin, white, glistening, and at times wrinkled. Hypertrophic pharyngitis is characterized by general thickening and congestion of the pharyngeal mucous membrane.
Wound drains, inserted during the laryngectomy, stay in place until what criteria are met?
Drainage is <30 mL/day for 2 consecutive days. Drains are removed when secretions are minimal, which usually is less than 30 mL for 48 straight hours.
In a client with amyotrophic lateral sclerosis (ALS) and respiratory distress, which finding is the earliest sign of reduced oxygenation?
Increased restlessness In ALS, an early sign of respiratory distress is increased restlessness, which results from inadequate oxygen flow to the brain. As the body tries to compensate for inadequate oxygenation, the heart rate increases and blood pressure drops. A decreased LOC is a later sign of poor tissue oxygenation in a client with respiratory distress.
A young adult visited a clinic because he was injured during a softball game. He told the nurse that the ball struck him in his "Adam's apple." To assess the initial impact of injury, the nurse:
Palpates the thyroid cartilage. The term "Adam's Apple" is used to refer to a lump or protrusion, a laryngeal prominence. It is formed by the angle of the thyroid cartilage surrounding the larynx.
Influenza, an annual epidemic in the U.S., creates a significant increase in hospitalizations and an rise in the death rates from pneumonia and cardiovascular disease. Besides death, what is the most serious complication of influenza?
staphylococcal pneumonia Complications include tracheobronchitis, bacterial pneumonia, and cardiovascular disease, however staphylococcal pneumonia is the most serious complication.
A client is being discharged from an outpatient surgery center following a tonsillectomy. What instruction should the nurse give to the client?
"Gargle with a warm salt solution." A warm saline solution will help with removal of thick mucus and halitosis. It will be a gentle gargle, because a vigorous gargle may cause bleeding. A sore throat may be present for 3 to 5 days. Hot foods should be avoided.
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" During a pulmonary angiography, a contrast medium is injected into the femoral circulation. When the medium is infused, the client will feel warm and flushed, with a possiblity of chest pain. The client will feel pressure when the catheter is inserted. The client does not typically feel light-headed or nauseated during this procedure.
What dietary recommendations should a nurse provide a client with a lung abscess?
A diet rich in protein For a client with lung abscess, a diet rich in protein and calories is integral because chronic infection is associated with a catabolic state. A carbohydrate-dense diet or diets with limited fat are not advisable for a client with lung abscess.
The nurse is educating the patient diagnosed with acute pharyngitis on methods to alleviate discomfort. What interventions should the nurse include in the information? (Select all that apply.)
Apply an ice collar. Stay on bed rest during the febrile stage of the illness. Try a liquid or soft diet during the acute stage of the disease. A liquid or soft diet is provided during the acute stage of the disease, depending on the patient's appetite and the degree of discomfort that occurs with swallowing. Cool beverages, warm liquids, and flavored frozen desserts such as ice pops are often soothing. The nurse instructs the patient to stay in bed during the febrile stage of illness and to rest frequently once up and about. Depending on the severity of the pharyngitis and the degree of pain, warm saline gargles or throat irrigations are used. An ice collar also can relieve severe sore throats.
The nurse is caring for the client in the intensive care unit immediately after removal of the endotracheal tube. Which of the following nursing actions is most important to complete every hour to ensure that the respiratory system is not compromised?
Auscultate lung sounds. Major goals of intubation are to improve respirations and maintain a patent airway for gas exchange. Regular auscultation of the lung fields is essential in confirming that air is reaching the lung fields for gas exchange. All other options are important to provide assessment data.
The nurse is obtaining data from a client with a respiratory disorder. Which information would be considered a part of the functional assessment and would assist in the diagnosis of an occupational lung disease?
Black-streaked sputum A functional assessment provides data on the lifestyle, living environment, and work environment of the client, which can contribute to lung disorders. A black-tinged sputum is suggestive of prolonged exposure to coal dust. Cough, dyspnea, and tenacious secretions are vague respiratory symptoms that are not specific to occupational lung disease. The presence of barrel chest is indicative of trapped oxygen in the lungs over a prolonged period of time.
A victim has sustained a blunt force trauma to the chest. A pulmonary contusion is suspected. Which of the following clinical manifestations correlate with a moderate pulmonary contusion?
Blood-tinged sputum The clinical manifestations of pulmonary contusions are based on the severity of bruising and parenchymal involvement. The most common signs and symptoms are crackles, decreased or absent bronchial breath sounds, dyspnea, tachypnea, tachycardia, chest pain, blood-tinged secretions, hypoxemia, and respiratory acidosis. Patients with moderate pulmonary contusions often have a constant, but ineffective cough and cannot clear their secretions.
A nurse is caring for a patient diagnosed with empyema. Which of the following interventions does a nurse implement for patients with empyema?
Encourage breathing exercises. The nurse teaches the patient with empyema to do breathing exercises as prescribed. The nurse should institute droplet precautions, isolate suspected and confirmed influenza patients in private rooms, or place suspected and confirmed patients together, and not allow visitors with symptoms of respiratory infection to visit the hospital to prevent outbreaks of influenza from occurring in health care settings.
You are caring for a client who has been diagnosed with viral pneumonia. You are making a plan of care for this client. What nursing interventions would you put into the plan of care for a client with pneumonia?
Encourage increased fluid intake. The nurse places the client in semi-Fowler's position to aid breathing and increase the amount of air taken with each breath. Increased fluid intake is important to encourage because it helps to loosen secretions and replace fluids lost through fever and increased respiratory rate. The nurse monitors fluid intake and output, skin turgor, vital signs, and serum electrolytes. He or she administers antipyretics as indicated and ordered. Antibiotics are not given for viral pneumonia. The client's activity level is ordered by the physician, not decided by the nurse.
The nurse is assessing a client's potential for pulmonary emboli. What finding indicates possible deep vein thrombosis?
Localized calf tenderness If the client were to complain of localized calf tenderness, the nurse would know this is a possible indication of a deep vein thrombosis. The area of tenderness could also be warm to touch. The client's urine output should not be impacted. Pain in the feet is not an indication of possible deep vein thrombosis.
Which oxygen administration device has the advantage of providing a high oxygen concentration?
Nonrebreathing mask The nonrebreathing mask provides high oxygen concentration, but it usually fits poorly. However, if the nonrebreathing mask fits the client snugly and both side exhalation ports have one-way valves, it is possible for the client to receive 100% oxygen, making the nonrebreathing mask a high-flow oxygen system. The Venturi mask provides low levels of supplemental oxygen. The catheter is an inexpensive device that provides a variable fraction of inspired oxygen and may cause gastric distention. A face tent provides a fairly accurate fraction of inspired oxygen but is bulky and uncomfortable. It would not be the device of choice to provide a high oxygen concentration.
A client with myasthenia gravis is receiving continuous mechanical ventilation. When the high-pressure alarm on the ventilator sounds, what should the nurse do?
Suction the client's artificial airway. A high-pressure alarm on a continuous mechanical ventilator indicates an obstruction in the flow of gas from the machine to the client. The nurse should suction the client's artificial airway to remove respiratory secretions that could be causing the obstruction. The sounding of a ventilator alarm has no relationship to the apical pulse. Increasing the oxygen percentage and ventilating with a handheld mechanical ventilator wouldn't correct the airflow blockage.
The nurse is admitting a client who just had a bronchoscopy. Which assessment should be the nurse's priority?
Swallow reflex The physician sprays a local anesthetic into the client's throat before performing a bronchoscopy. The nurse must assess the swallow reflex when the client returns to the unit and before giving him anything by mouth. The nurse should also assess for medication allergies, carotid pulse, and deep breathing, but they aren't the priority at this time.
A nurse observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude?
The system has an air leak. Constant bubbling in the water-seal chamber indicates an air leak and requires immediate intervention. The client with a pneumothorax will have intermittent bubbling in the water-seal chamber. Clients without a pneumothorax should have no evidence of bubbling in the chamber. If the tube is obstructed, the fluid would stop fluctuating in the water-seal chamber.
While caring for a client with a chest tube, which nursing assessment would alert the nurse to a possible complication?
The tissues give a crackling sensation when palpated. Subcutaneous emphysema is the result of air leaking between the subcutaneous layers. It is not a serious complication but is notable and reportable. Pink skin and blood in the collection chamber are normal findings. When two tubes are inserted, the posterior or lower tube drains fluid,whereas the anterior or upper tube is for air removal.
Which statement describes emphysema?
a disease of the airways characterized by destruction of the walls of overdistended alveoli Emphysema is a category of chronic obstructive pulmonary disease (COPD). In emphysema, impaired oxygen and carbon dioxide exchange results from destruction of the walls of overdistended alveoli. Emphysema is a pathologic term that describes an abnormal distention of the airspaces beyond the terminal bronchioles and destruction of the walls of alveoli; a chronic inflammatory response may induce disruption of the parenchymal tissues. Asthma has a clinical outcome of airflow obstruction. Bronchitis includes the presence of cough and sputum production for at least a combined total of 2 to 3 months in each of two consecutive years. Bronchiectasis is a condition of chronic dilatation of a bronchus or bronchi.
A client with supraglottic cancer undergoes a partial laryngectomy. Postoperatively, a cuffed tracheostomy tube is in place. When removing secretions that pool above the cuff, the nurse should instruct the client to:
cough as the cuff is being deflated. The nurse should instruct the client to cough during cuff deflation. If the client can't cough, the nurse should perform suctioning to prevent aspiration of secretions. Because the cuff should be deflated during expiration, the client shouldn't take a deep breath as the nurse deflates the cuff. Likewise, because the cuff is reinflated during inspiration, the client shouldn't hold the breath or exhale deeply during reinflation.
A client has a tracheostomy but doesn't require continuous mechanical ventilation. When weaning the client from the tracheostomy tube, the nurse initially should plug the opening in the tube for:
5 to 20 minutes. Initially, the nurse should plug the opening in the tracheostomy tube for 5 to 20 minutes, then gradually lengthen this interval according to the client's respiratory status. A client who doesn't require continuous mechanical ventilation already is breathing without assistance, at least for short periods; therefore, plugging the opening of the tube for only 15 to 60 seconds wouldn't be long enough to reveal the client's true tolerance to the procedure. Plugging the opening for more than 20 minutes would increase the risk of acute respiratory distress because the client requires an adjustment period to start breathing normally.
The nurse is caring for a client who is in respiratory distress. The physician orders arterial blood gases (ABGs) to determine various factors related to blood oxygenation. What site can ABGs be obtained from?
A puncture at the radial artery ABGs determine the blood's pH, oxygen-carrying capacity, levels of oxygen, CO2, and bicarbonate ion. Blood gas samples are obtained through an arterial puncture at the radial, brachial, or femoral artery. A client also may have an indwelling arterial catheter from which arterial samples are obtained. Blood gas samples are not obtained from the pleural surfaces or trachea and bronchi.
A client experiencing an asthmatic attack is prescribed methylprednisolone intravenously. What action should the nurse take?
Assesses fasting blood glucose levels Adverse effects of methylprednisolone (Solu-Medrol) include abnormalities in glucose metabolism. The nurse monitors blood glucose levels. Methylprednisolone also increases the client's appetite and fluid retention, but the client will not decrease caloric or fluid intake as a result of these adverse effects. It is not necessary to aspirate for blood return prior to injecting the medication, because doing so would not support the intravenous line in the vein.
After a tonsillectomy, a client is being prepared for discharge. The nurse should instruct the client to report which sign or symptom immediately?
Bleeding The nurse should instruct the client to report bleeding immediately. Delayed bleeding may occur when the healing membrane separates from the underlying tissue — usually 7 to 10 days postoperatively. Difficulty swallowing and throat pain are expected after a tonsillectomy and typically are present even before the client is discharged. Sudden difficulty talking wouldn't occur after discharge if the client could talk normally at the time of discharge, because swelling doesn't take that long to develop.
Which is a priority nursing intervention that the nurse should perform for a client who has undergone surgery for a nasal obstruction?
Ensure mouth breathing For a client who has undergone surgery for a nasal obstruction, it is important for the nurse to emphasize that nasal packing will be in place postoperatively, necessitating breathing through the mouth. The nurse applies an ice pack to reduce pain and swelling and not a warm pack. The nurse recommends the use of a splint and the application of pressure to the convex portion of the nose in case of a nasal fracture.
A physician wants a study of diaphragmatic motion because of suspected pathology. What does the nurse anticipate that the physician will most likely order?
Fluoroscopy Fluoroscopy, which allows live x-ray images to be generated via a camera to a video screen, is used to assist with invasive procedures, such as a chest needle biopsy or transbronchial biopsy, that are performed to identify lesions. It also may be used to study the movement of the chest wall, mediastinum, heart, and diaphragm; to detect diaphragm paralysis; and to locate lung masses.
The nurse has instructed a client on how to perform pursed-lip breathing. The nurse recognizes the purpose of this type of breathing is to accomplish which result?
Improve oxygen transport; induce a slow, deep breathing pattern; and assist the client to control breathing Pursed-lip breathing, which improves oxygen transport, helps induce a slow, deep breathing pattern and assists the client to control breathing, even during periods of stress. This type of breathing helps prevent airway collapse secondary to loss of lung elasticity in emphysema.
A client with suspected severe acute respiratory syndrome (SARS) comes to the emergency department. Which physician order should the nurse implement first?
Institute isolation precautions. SARS, a highly contagious viral respiratory illness, is spread by close person-to-person contact. Contained in airborne respiratory droplets, the virus is easily transmitted by touching surfaces and objects contaminated with infectious droplets. The nurse should give top priority to instituting infection-control measures to prevent the spread of infection to emergency department staff and clients. After isolation measures are carried out, the nurse can begin an I.V. infusion of dextrose 5% in half-normal saline and obtain nasopharyngeal and sputum specimens.
A client suffers acute respiratory distress syndrome as a consequence of shock. The client's condition deteriorates rapidly, and endotracheal (ET) intubation and mechanical ventilation are initiated. When the high-pressure alarm on the mechanical ventilator sounds, the nurse starts to check for the cause. Which condition triggers the high-pressure alarm?
Kinking of the ventilator tubing Conditions that trigger the high-pressure alarm include kinking of the ventilator tubing, bronchospasm, pulmonary embolus, mucus plugging, water in the tube, and coughing or biting on the ET tube. The alarm may also be triggered when the client's breathing is out of rhythm with the ventilator. A disconnected ventilator circuit or an ET cuff leak would trigger the low-pressure alarm. Changing the oxygen concentration without resetting the oxygen level alarm would trigger the oxygen alarm, not the high-pressure alarm.
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. Assessment of lung sounds includes auscultation for airflow through the bronchial tree. The nurse evaluates for fluid or solid obstruction in the lung. When airflow is decreased, as with fluid or secretions, adventitious sounds may be auscultated. Often crackles are heard with fluid in the airways.
A client is postoperative for a partial laryngectomy following a diagnosed malignancy. The client is to start oral feedings. The nurse does the following interventions: (Select all that apply.)
Obtains results of a swallow study Provides thick liquids When a client is allowed to eat following a partial laryngectomy, a swallow study may be obtained first to determine the client's risk of aspiration. The client is started with thick liquids because they are easy to swallow. The nurse stays with the client during initial feedings to ensure safe ingestion. Solid foods are introduced as tolerated. The nurse encourages the client to avoid sweet foods, which increase salivation and suppress appetite.
A client is being seen in the emergency department for exacerbation of chronic obstructive pulmonary disease (COPD). The first action of the nurse is to administer which of the following prescribed treatments?
Oxygen through nasal cannula at 2 L/minute When a client presents in the emergency department with an exacerbation of COPD, the nurse should first administer oxygen therapy and perform a rapid assessment of whether the exacerbation is potentially life threatening.
A client has been receiving 100% oxygen therapy by way of a nonrebreather mask for several days. Now the client complains of tingling in the fingers and shortness of breath, is extremely restless, and describes a pain beneath the breastbone. What should the nurse suspect?
Oxygen toxicity Oxygen toxicity may occur when too high a concentration of oxygen (greater than 50%) is administered for an extended period (longer than 48 hours) (Urden, Stacy, & Lough, 2014). Signs and symptoms of oxygen toxicity include substernal discomfort, paresthesias, dyspnea, restlessness, fatigue, malaise, progressive respiratory difficulty, refractory hypoxemia, alveolar atelectasis, and alveolar infiltrates evident on chest x-rays.
A client who has just had a triple-lumen catheter placed in his right subclavian vein complains of chest pain and shortness of breath. His blood pressure is decreased from baseline and, on auscultation of his chest, the nurse notes unequal breath sounds. A chest X-ray is immediately ordered by the physician. What diagnosis should the nurse suspect?
Pneumothorax Pneumothorax (air in the pleural space) is a potential complication of all central venous access devices. Signs and symptoms include chest pain, dyspnea, shoulder or neck pain, irritability, palpitations, light-headedness, hypotension, cyanosis, and unequal breath sounds. A chest X-ray reveals the collapse of the affected lung that results from pneumothorax. Triple-lumen catheter insertion through the subclavian vein isn't associated with pulmonary embolism, MI, or heart failure.
The nurse is assessing a client who, after an extensive surgical procedure, is at risk for developing acute respiratory distress syndrome (ARDS). The nurse assesses for which most common early sign of ARDS?
Rapid onset of severe dyspnea The acute phase of ARDS is marked by a rapid onset of severe dyspnea that usually occurs less than 72 hours after the precipitating event.
Which action by the nurse is most appropriate when the client demonstrates subcutaneous emphysema along the suture line or chest dressing 2 hours after chest surgery?
Record the observation The nurse should record the observation. Subcutaneous emphysema is a typical finding in clients after chest surgery. Subcutaneous emphysema occurs after chest surgery as the air that is located within the pleural cavity is expelled through the tissue opening created by the surgical procedure. Subcutaneous emphysema is absorbed by the body spontaneously after the underlying leak is treated or halted. Subcutaneous emphysema results from air entering the tissue planes. It is unnecessary to report the finding to the physician or apply a compression dressing because subcutaneous emphysema is an expected finding at this stage of recovery. Subcutaneous emphysema is not an explicit risk factor for hypoxemia, so no extraordinary monitoring of pulse oximetry is necessary.
A client is being discharged following pelvic surgery. What would be included in the patient care instructions to prevent the development of a pulmonary embolus?
Tense and relax muscles in the lower extremities. Clients are encouraged to perform passive or active exercises, as tolerated, to prevent a thrombus from forming. Constrictive, tight-fitting clothing is a risk factor for the development of a pulmonary embolism in postoperative clients. Clients at risk for a DVT or a pulmonary embolism are encouraged to drink throughout the day to avoid dehydration. Estrogen replacement is a risk factor for the development of a pulmonary embolism.
A client has been hospitalized for treatment of acute bacterial pneumonia. Which outcome indicates an improvement in the client's condition?
The client has a partial pressure of arterial oxygen (PaO2) value of 90 mm Hg or higher. As the acute phase of bacterial pneumonia subsides, normal lung function returns and the PaO2 typically rises, reaching 85 to 100 mm Hg. A PaCO2 of 65 mm Hg or higher is above normal and indicates CO2 retention — common during the acute phase of pneumonia. Restlessness and confusion indicate hypoxia, not an improvement in the client's condition. Bronchial breath sounds over the affected area occur during the acute phase of pneumonia; later, the affected area should be clear on auscultation.
After lobectomy for lung cancer, a client receives a chest tube connected to a disposable chest drainage system. The nurse observes that the drainage system is functioning correctly when she notes tidal movements or fluctuations in which compartment of the system as the client breathes?
Water-seal chamber Fluctuations in the water-seal compartment are called tidal movements and indicate normal function of the system as the pressure in the tubing changes with the client's respirations. The air-leak meter — not chamber — detects air leaking from the pleural space. The collection chamber connects the chest tube from the client to the system. Drainage from the tube drains into and collects in a series of calibrated columns in this chamber. The suction control chamber provides the suction, which can be controlled to provide negative pressure to the chest.
After undergoing a left thoracotomy, a client has a chest tube in place. When caring for this client, the nurse must:
encourage coughing and deep breathing. When caring for a client who's recovering from a thoracotomy, the nurse should encourage coughing and deep breathing to prevent pneumonia. Fluctuations in the water-seal chamber are normal. Clamping the chest tube could cause a tension pneumothorax. Chest tube milking is controversial and should be done only to remove blood clots that obstruct the flow of drainage.
The nurse answers a client's call light. The client reports an irritating tickling sensation in the throat, a salty taste, and a burning sensation in the chest. Upon further assessment, the nurse notes a tissue with bright red, frothy blood at the bedside. The nurse can assume the source of the blood is likely from the
lungs Blood from the lung is usually bright red, frothy, and mixed with sputum. Initial symptoms include a tickling sensation in the throat, a salty taste, a burning or bubbling sensation in the chest, and perhaps chest pain, in which case the client tends to splint the bleeding side. This blood has an alkaline pH (>7.0). Blood from the stomach is vomited rather than expectorated, may be mixed with food, and is usually much darker; it is often referred to as "coffee ground emesis." This blood has an acidic pH (<<7.0). Bloody sputum from the nose or the nasopharynx is usually preceded by considerable sniffing, with blood possibly appearing in the nose.
The classification of Stage II of COPD is defined as
moderate COPD. Stage II is moderate COPD. Stage 0 is at risk for COPD. Stage I is mild COPD. Stage III is severe COPD. Stage IV is very severe COPD.
In relation to the structure of the larynx, the cricoid cartilage is
the only complete cartilaginous ring in the larynx. The cricoid cartilage is located below the thyroid cartilage. The arytenoid cartilages are used with the thyroid cartilage in vocal cord movement. The thyroid cartilage is the largest of the cartilage structures and part of it forms the Adam's apple. The epiglottis is the valve flap of cartilage that covers the opening to the larynx during swallowing.