Adult Nursing 2 - Chapter 20 PrepU

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? "Anytime there is a chronic disease process it is hard for the person to breathe." "Having a chronic respiratory disease scars the lung and affects the effort it takes to breathe." "In this particular case your family member is just overly tired and having problems breathing." "Conditions such as chronic bronchitis cause thickening of the bronchial mucosa so it makes it harder to breathe."

"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 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 The trachea and bronchi The pleural surfaces A catheter in the arm vein

A puncture at the radial artery

The nurse is caring for a client diagnosed with pneumonia. The nurse assesses the client for tactile fremitus by completing which action? Placing the thumbs along the costal margin of the chest wall and instructing the client to inhale deeply Asking the client to repeat "ninety-nine" as the nurse's hands move down the client's thorax Asking the client to say "one, two, three" while the nurse auscultates the lungs Instructing the client to take a deep breath and hold it while the diaphragm is percussed

Asking the client to repeat "ninety-nine" as the nurse's hands move down the client's thorax

If concern exists about fluid accumulation in a client's lungs, what area of the lungs will the nurse focus on during assessment? Bilateral lower lobes Anterior bronchioles Posterior bronchioles Left lower lobe

Bilateral lower lobes

What finding by the nurse may indicate that the client has chronic hypoxia? Crackles Peripheral edema Clubbing of the fingers Cyanosis

Clubbing of the fingers

The nurse is assessing a patient in respiratory failure. What finding is a late indicator of hypoxia? Clubbing of fingers Cyanosis Crackles Restlessness

Cyanosis

The nurse is caring for a client in the immediate post-thoracentesis period. In which position is the client placed? In the supine position Lying on the unaffected side In the high Fowler's position Prone with a pillow under the head

Lying on the unaffected side

What is the primary function of the larynx? Producing sound Protecting the lower airway from foreign objects Facilitating coughing Preventing infection

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? Watery sputum Loss of consciousness Respiratory distress Masses in pleural space

Respiratory distress

In which position should the client be placed for a thoracentesis? Prone Sitting on the edge of the bed Supine Lateral recumbent

Sitting on the edge of the bed

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. stomach. nose. rectum.

lungs.

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. crackles. sonorous wheezes. sibilant wheezes.

pleural friction rub.

The amount of air inspired and expired with each breath is called: vital capacity. dead-space volume. tidal volume. residual volume.

tidal volume.

The volume of air inhaled and exhaled with each breath is termed residual volume. tidal volume. vital capacity. expiratory reserve volume.

tidal volume.

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 Dyspnea Restlessness Confusion

Cyanosis

While conducting the physical examination during assessment of the respiratory system, which conditions does the nurse assess by inspecting and palpating the trachea? Evidence of exudate Color of the mucous membranes Deviation from the midline Evidence of muscle weakness

Deviation from the midline

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? Increased temperature of the room Reduced lighting in the room Placement of the probe on an earlobe Diagnosis of peripheral vascular disease

Diagnosis of peripheral vascular disease

What would the instructor tell the students purulent fluid indicates? Cancer Infection Inflammation Heart failure

Infection

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? Bleeding Iodine allergy Dysrhythmias Inflammation

Iodine allergy

A physician has ordered that a client with suspected lung cancer undergo magnetic resonance imaging (MRI). The nurse explains the benefits of this study to the client. What is the reason the client with suspected lung cancer would undergo magnetic resonance imaging (MRI)? Lung blood flow can be viewed after a radiopaque agent is injected. Narrow-beam x-ray can scan successive lung layers. MRI can view soft tissues and can help stage cancers. Tumor densities can be seen with radiolucent images.

MRI can view soft tissues and can help stage cancers.

Upon palpation of the sinus area, what would the nurse identify as a normal finding? Light not going through the sinus cavity Tenderness during palpation Pain sensation behind the eyes No sensation during palpation

No sensation during palpation

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? Dyspnea Orthopnea Tachypnea Bradypnea

Orthopnea

The nurse is caring for a client whose respiratory status has declined since shift report. The client has tachypnea, is restless, and displays cyanosis. Which diagnostic test should be assessed first? Arterial blood gases Pulmonary function test Pulse oximetry Chest x-ray

Pulse oximetry

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? Prone Sitting on the edge of the bed Supine Lateral recumbent

Sitting on the edge of the bed

Which homeostatic mechanism would the body of a critically ill client use to maintain normal pH? The lungs eliminate carbonic acid by blowing off more CO2. The lungs increase respiratory volume. The lungs retain more CO2 to lower the pH. The kidneys retain more HCO3 to raise the pH.

The lungs eliminate carbonic acid by blowing off more CO2.

A client experiences a head injury in a motor vehicle accident. The client's level of consciousness is declining, and respirations have become slow and shallow. When monitoring a client's respiratory status, which area of the brain would the nurse realize is responsible for the rate and depth? The pons The frontal lobe Central sulcus Wernicke's area

The pons

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 result from air passing through widened air passages. They can be heard during inspiration and expiration. They are heard in clients with decreased secretions. They occur when the pleural surfaces are inflamed.

They can be heard during inspiration and expiration.

A client has recently been diagnosed with malignant lung cancer. The nurse is calculating the client's smoking history in pack-years. The client reports smoking two packs of cigarettes a day for the past 11 years. The nurse correctly documents the client's pack-years as 5. 11. 22. 10.

22.

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? Rales Crackles Wheezes Rhonchi

Wheezes

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? Raised temperature in the affected limb Excessive capillary refill Absent distal pulses Flushed feeling in the client

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. Avoid sedatives or narcotics as they depress the vagus nerve. Avoid atropines as they dry the secretions. Practice holding the breath for short periods.

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? Ensure the client remains moderately sedated to decrease anxiety. Offer the client ice chips. Assess the client for a cough reflex. Instruct the client that bed rest must be maintained for 2 hours.

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? Acute respiratory obstruction Pneumothorax Asthma Adult respiratory distress syndrome

Asthma

A client appears to be breathing faster than during the last assessment. Which of the following interventions should the nurse perform? Inquire if there have been any stressful visitors. Assist the client to lie down. Count the rate of respirations. Assess the radial pulse.

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 Egophony Absent breath sounds Bronchial breath sounds

Crackles at lung bases

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? Respiratory rate Cyanosis Son's statement Crackles

Cyanosis

A nurse is preparing a client for bronchoscopy. Which instruction should the nurse give to the client? Do not walk after the procedure for 4 to 6 hours. Do not cough after the procedure until you are walking. Do not talk for 2 hours before the procedure. Do not eat or drink for 6 hours before the procedure.

Do not eat or drink for 6 hours before the procedure.

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? Tympanic Resonant Hyperresonant Dull

Dull

High or increased compliance occurs in which disease process? Emphysema ARDS Pleural effusion Pneumothorax

Emphysema

You are assessing the respiratory system of a client just admitted to your unit. What do you know to assess in addition to the physical and functional issues related to breathing? How these issues affect the client's quality of life How these issues affect the relationships in the client's life How these issues affect the client's effort to breathe How these issues affect the client's ability to function

How these issues affect the client's quality of life

A nurse is concerned that a client may develop postoperative atelectasis. Which nursing diagnosis would be most appropriate if this complication occurs? Ineffective airway clearance Impaired gas exchange Decreased cardiac output Impaired spontaneous ventilation

Impaired gas exchange

Which respiratory volume is the maximum volume of air that can be inhaled after maximal expiration? Tidal volume Expiratory reserve volume Residual volume Inspiratory reserve volume

Inspiratory reserve volume

A patient diagnosed with diabetic ketoacidosis would be expected to have which type of respiratory pattern? Kussmaul respirations Cheyne-Stokes Biot's respirations Apnea

Kussmaul respirations

When assessing a client, which adaptation indicates the presence of respiratory distress? Respiratory rate of 14 breaths per minute Productive cough Sore throat Orthopnea

Orthopnea

Which term will the nurse use to document the inability of a client to breathe easily unless positioned upright? Dyspnea Orthopnea Hemoptysis Hypoxemia

Orthopnea

A patient comes to the emergency department complaining of a knifelike pain when taking a deep breath. What does this type of pain likely indicate to the nurse? Bacterial pneumonia Bronchogenic carcinoma Lung infarction Pleurisy

Pleurisy

A client with chronic bronchitis is admitted to the health facility. Auscultation of the lungs reveals low-pitched, rumbling sounds. Which term should the nurse document? Crackles Pleural friction rub Rhonchi Bronchial

Rhonchi

The client is returning from the operating room following a bronchoscopy. Which action, performed by the nursing assistant, would the nurse stop if began prior to nursing assessment? The nursing assistant is assisting the client to a semi-Fowler's position. The nursing assistant is assisting the client to the side of the bed to use a urinal. The nursing assistant is pouring a glass of water to wet the client's mouth. The nursing assistant is asking a question requiring a verbal response.

The nursing assistant is pouring a glass of water to wet the client's mouth.

Which term refers to the volume of air inhaled or exhaled during each respiratory cycle? Vital capacity Functional residual capacity Tidal volume Maximal voluntary ventilation

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 To move CO2 out of the atmospheric air and into the expired air To move O2 out of the atmospheric air and into the retained air To exchange atmospheric air between the blood and the cells

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

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 I cells Type II cells Type III cells Type IV cells

Type II cells

A nurse assesses a client's respiratory status. Which observation indicates that the client is having difficulty breathing? Diaphragmatic breathing Use of accessory muscles Pursed-lip breathing Controlled breathing

Use of accessory muscles

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? Perfusion exceeds ventilation. There is an absence of perfusion and ventilation. Ventilation exceeds perfusion. Ventilation matches perfusion.

Ventilation exceeds perfusion.

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. raise the arm on the side of the client's body on which the physician will perform the thoracentesis. place the client supine in the bed, which is flat. raise the head of the bed to a high Fowler's position.

assist the client to a sitting position on the edge of the bed, leaning over the bedside table.

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 genetics oropharynx epiglottis

eustachian tubes

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. is when the body changes oxygen into CO2. provides a blood supply to the lungs. helps people who cannot breathe on their own.

is breathing air in and out of the lungs.