ATI Health Asses 2.0: Respiratory

A nurse is providing teaching to a client who has a new diagnosis of asthma and reports a smoking history of 20 years. Which of the following statements should the nurse make when counseling the client about their tobacco use? (select all that apply) 1. "Smoking is linked to various forms of cancer" 2. "There are no risks associated with exposure to second hand smoke" 3. "It might take several attempts to finally stop smoking" 4. "Smoking will cause you to die years earlier than if you didn't smoke" 5. "There are pharmacological therapies that can help a person stop smoking"

1. "Smoking is linked to various forms of cancer" 3. "It might take several attempts to finally stop smoking" 5. "There are pharmacological therapies that can help a person stop smoking" Rationale: Education, preparing a smoking cessation plan that includes cognitive and pharmacological therapies.

A nurse is caring for a client who is dying and is having periods of deep breathing alternating with periods of apnea. The nurse should identify this as which of the following types of breathing? A. Thoracic breathing B. Cheyne-Stokes breathing C. Bradypnea D. Kussmaul's breathing

B. Cheyne-Stokes breathing Rationale: Cheyne-Stokes breathing can occur if the Central Nervous System is grossly affected by lack of oxygen or disease progression. It appears to have a respiratory "start-stop" pattern. The client will have a deeper breath that might quicken, followed by hypoventilation and progression to apnea. This is an END-OF-LIFE breathing pattern.

A nurse is reviewing the medical record of a client who was assessed as having a barrel chest resulting from COPD. Which of the following images shows a client who has a barrel chest.

Barrel chest is caused by hyperinflation of the lungs due to a disease process such as COPD. It can also be a part of the normal aging process. The transverse diameter is equal and the ribs are in a downward slope. Client might be sitting in a tri-pod position to obtain adequate oxygen exchange.

A nurse is caring for a client who is having difficulty breathing. Which of the following actions should the nurse take first ? A. Instruct the client to deep breathe and cough. B. Provide the client with an incentive spirometer C. Elevate the head of the client's bed D. Reassess by auscultating the client's lungs.

C. Elevate the head of the client's bed Rationale: According to evidence based practice the first actions a nurse should take is to elevate the head of the bed. Raising the head to a semi-fowlers or high-fowlers will allow for lung expansion.

A charge nurse is teaching a newly licensed nurse how to recognize a pleural friction rub. Which of the following descriptions should the nurse use to describe a pleural friction rub? (select all that apply) 1. Coarse grating tone 2. Intermittent popping or bubbling sound 3. Heard on inspiration and expiration 4. Snoring sound on expiration 5. Pain with breathing

1. Coarse grating tone 3. Heard on inspiration and expiration 5. Pain with breathing Rationale: A pleura friction rub occurs because of inflammation of the pleura. It is a low-pitched, coarse grating tone that sounds like rubbing two pieces of leather together. It can be heard on inspiration and expiration and is very painful.

A nurse is caring for a client who is experiencing episodes of hyperventilation. Which of the following manifestations should the nurse expect during hyperventilation? (select all that apply) 1. Numbness and tingling of the extremities 2. Decreased chest wall expansion 3. Lightheadedness 4. Periods of apnea 5. Chest Pain

1. Numbness and tingling of the extremities 3. Lightheadedness 5. Chest Pain Rationale: A client who is hyperventilating can show manifestations of numbness and tingling in the extremities, heart palpitations, chest pain and lightheadedness.

A nurse is assessing a client who is dark-skinned. In which of the following areas of the client's body should the nurse assess the client for adequate oxygenation? (select all that apply) 1. Cheeks 2. Nail beds 3. Oral mucosa 4. Sclera 5. Lips

2. Nail beds 3. Oral Mucosa 5. Lips Rationale: Nail beds with be pink regardless of skin complexity. Oral mucosa should be inspected. Lips should be inspected also.

A nurse is performing a head to toe assessment of a client. Which of the following findings indicate the client might be experiencing respiratory difficulty? (select all that apply) 1. The client occasionally sighs 2. The client is sitting in a tripod position 3. The client's respiratory rate is 18/min 4. The client is using pursed lips breathing. 5. The client appears confused

2. The client is sitting in a tripod position 4. The client is using pursed lips breathing. 5. The client appears confused Rationale: Tripod positioning uses accessory muscles to facilitate breathing. Pursed lips is a technique used by COPD clients who are having respiratory difficulty. Confusion can indicate hypoxia and a lack of O2 to the brain.

A charge nurse is observing a newly licensed nurse perform an anterior chest auscultation on a client. For which of the following actions should the charge nurse intervene? A. The nurse asks the client to cough before the beginning the auscultation. B. The nurse is auscultating through the client's gown. C. The nurse places the stethoscope on the intercostal spaces D. The nurse moves down the chest in a ladder sequence

B. The nurse is auscultating through the client's gown Rationale: The stethoscope should be placed directly on skin. Auscultating through clothes can produce crackling or abnormal sounds and obstruct air movement.

A charge nurse is teaching a newly licensed nurse how to recognize manifestations of decreased oxygenation in a client. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching. A. "A client using thoracic breathing is experiencing a lack of oxygen" B. "A pulse oximeter reading of less than 95% indicates respiratory distress" C. "Clubbing of the fingers indicates a chronic state of impaired perfusion" D. "A pinkish hue on the cheeks is an indication of adequate oxygenation in a client who is light-skinned"

C. Clubbing of the fingers indicates a chronic state of impaired perfusion. Rationale: Clubbing of the ends of fingers can indicate a chronic state of decreased oxygenation and perfusion.

A nurse is providing discharge teaching to a client who has COPD regarding the influenza vaccine. Which of the following statements should the nurse make? A. "It's just a small number of people who get the the flu from receiving the vaccine" B. "Call your provider immediately if you have flu-like symptoms after receiving the vaccine" C. "You should make every effort to receive a flu vaccine every year" D. "The vaccine becomes effective immediately after the injection"

C. You should make every effort to receive a flu vaccine every year Rationale: The nurse should explain the CDC recommends everyone 6 months of age or older receive an annual flu vaccine. Influenza can cause serious respiratory complications, even death especially in the immunocompromised.

A charge nurse is reviewing the documentation of a newly licensed nurse. Which of the following entries made by the newly licensed nurse is an example of correct documentation. A. I cannot sleep at night because i get short if breath B. Client seems to not like certain staff C. Client's partner does not visit the client enough D. Inspiratory wheezing auscultated at the left lateral chest.

D. Inspiratory wheezing auscultated at left lateral chest. Rationale: Objective data that is descriptive and based on facts. Provides an accurate picture of the client's respiratory assessment.

A nurse in the ED is assessing a client who has experienced thoracic trauma from a motor-vehicle crash. Which of the following findings is an indication of a pneumothorax? A. Client's ribs slope downward at a 45 degree angle. B. The client is making a high-pitched crowning sound that can be heard in the neck area. C. The diameter of the client's chest appears barrel-like with horizontal ribs. D. The client is experiencing unequal movement of the posterior chest.

D. The client is experiencing unequal movement of the posterior chest. Rationale: Unequal expansion of the posterior chest occurs during a pneumothorax or a collapsed lung. The client will be tachypneic with decreased or absent breath sounds on the affected side. A chest tube to re-inflate the lung is required to reverse a pneumothorax.

Auscultating the Posterior Chest steps

1. Expose the posterior chest with the client sitting with their arms folded across their chest. 2. Auscultate 8cm (3in) to one side of the spine around C7, then auscultate the other side of the spine in the same location. 3. Auscultate down the spine, moving the stethoscope from one side to the other until the lower thoracic spine is reached. 4. Auscultate the lateral sides slightly below the axillary area, then down to the seventh or eight rib

Auscultation Expected Sounds 1. Bronchial 2.Bronchiovesicular 3.Vesicular

1. Heard over the trachea. LOUD low-pitched and hollow. Longer expiration compared to inspiration. 2. Heard over large airway (bronchioles).MEDIUM pitched. Intensity same during inspiration and expiration. 3. Heard in peripheral areas of lungs. SOFT pitched breezy sounds

Define: 1. Rhonchi 2. Wheeze 3. Coarse crackles 4. Stridor

1. Rhonchi: continous, loud, low-pitched snoring-type sound heard during expiration. Caused by fluid or mucus and can be cleared with coughing. 2. Wheeze: high-pitched whistling as air flows through narrowed passages. usually louder on expiration. Can occur in asthma or bronchitis. 3. Coarse crackles: rales, rattling, popping, bubbling sound. Air passing through fluid or collapsed airways. Not cleared with coughing. 4. Stridor: high-pitched crowning sound heard in neck area without a stethoscope. Usually caused by obstruction on trachea. LIFE THREATENING SOUND

A nurse is admitting a client who has a new diagnosis of COPD. Which of the following information documented by the nurse is subjective data? (select all that apply) 1. Pulse oximeter reading is 89% on O2 2L/min via nasal cannula. 2. Report from client says they sleep while propped up on two pillows at night. 3. Client says the quit smoking 2 years ago 4. Respiratory rate increases to 28/min when client ambulates to restroom 5. Client states "Being short of breath all of the time is making me depressed"

2. Report from client says they sleep while propped up on two pillows at night. 3. Client says they quit smoking 2 years ago 5. Client states "Being short of breath all of the time is making me depressed" Rationale: Information reported by the client is subjective.