Assessment of Respiratory Function

The student nurse is caring for a client who has serial sputum tests ordered. The student asks the instructor why the sputum tests have to be repeated on successive days. What would be the instructor's best response?

"A negative sputum test does not always mean that there is no disease present, so more than one test may be needed."

The nurse is caring for a client with an exacerbation of COPD and scheduled for pulmonary function studies using a spirometer. Which client statement would the nurse clarify?

"I will breathe in through my mouth and out through my nose."

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"

Following a chest X-ray, a patient has been diagnosed with a pleural effusion. The care team has concluded that the quantity of fluid in the patient's intrapleural space necessitates thoracentesis. What patient education should the nurse provide in anticipation of this procedure?

"It's very important that you remain still while the doctor is performing the procedure."

A patient visited a health care clinic for treatment of upper respiratory tract congestion, fatigue, and sputum production that was rust-colored. Which of the following diagnoses is likely based on this history and inspection of the sputum?

An infection with pneumococcal pneumonia

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

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?

Dull

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)?

MRI can view soft tissues and can help stage cancers.

The nurse is admitting a client who just had a bronchoscopy. Which assessment should be the nurse's priority?

Swallow reflex

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.

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 volume of air inhaled and exhaled with each breath is termed

tidal volume.

A nurse would question the accuracy of a pulse oximetry evaluation in which of the following conditions?

A client experiencing hypothermia

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

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

What finding by the nurse may indicate that the client has chronic hypoxia?

Clubbing of the fingers

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

While assessing for tactile fremitus, the nurse palpates almost no vibration. Which of the following conditions in this client's history will account for this finding?

Emphysema

A patient is seen in the emergency room for a severe case of diabetic acidosis. The respiratory note indicates the presence of Kussmaul respirations. The nurse knows that this diagnosis is associated with which of the following?

Hyperventilation

A client arrived in the emergency department with a sharp object penetrating the diaphragm. When planning nursing care, which nursing diagnosis would the nurse identify as a priority?

Impaired Gas Exchange

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

You are performing pulmonary function studies on clients in the clinic. What position do you know a client should be in to have maximum lung capacities and volumes?

In the standing position

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

Upon palpation of the sinus area, what would the nurse identify as a normal finding?

No tenderness during palpation

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

In relation to the structure of the larynx, which describes the cricoid cartilage?

The only complete cartilaginous ring in the larynx

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 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 can be heard during inspiration and expiration.

You are studying for a physiology test about the respiratory system. What should you know about central chemoreceptors in the medulla?

They respond to changes in CO2 levels and hydrogen ion concentrations (pH) in the cerebrospinal fluid.

Which term refers to the volume of air inhaled or exhaled during each respiratory cycle?

Tidal volume

What is the difference between respiration and ventilation?

Ventilation is the movement of air in and out of the respiratory tract.

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

22

A nurse understands that a safe but low level of oxygen saturation provides for adequate tissue saturation while allowing no reserve for situations that threaten ventilation. What is a safe but low oxygen saturation level for a patient?

95%

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

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

The nurse is assessing a patient in respiratory failure. What finding is a late indicator of hypoxia?

Cyanosis

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 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

For air to enter the lungs (process of ventilation), the intrapulmonary pressure must be less than atmospheric pressure so air can be pulled inward. Select the movement of respiratory muscles that makes this happen during inspiration.

Diaphragm contracts and elongates the chest cavity.

A client with sinus congestion complains of discomfort when the nurse is palpating the supraorbital ridges. What sinus is the client referring?

Frontal

A patient diagnosed with diabetic ketoacidosis would be expected to have which type of respiratory pattern?

Kussmaul respirations

During a pulmonary assessment, the nurse observes the chest for configuration. She identifies the findings as normal. Which of the following would be consistent with normal assessment?

Lateral diameter greater than anteroposterior diameter

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.

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?

Pleurisy

The nurse is caring for a client with chronic obstructive pulmonary disease. The client reports that he is having difficulty breathing and is feeling fatigued. The nurse realizes that this client is at high risk for which condition?

Respiratory acidosis

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

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?

Rhonchi

An 18-month-old child is brought to the Emergency Department by parents who explain that their child swallowed a watch battery. Radiologic studies show that the battery is in the lungs. Which area of lung is the battery most likely to be in?

Right upper lung

What would the instructor tell the students purulent fluid indicates?

infection

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