Ch. 17

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 Clubbing of the fingers is a change in the normal nail bed. It appears as sponginess of the nail bed and loss of the nail bed angle. It is a sign of lung disease that is found in patients with chronic hypoxic conditions, chronic lung infections, or malignancies of the lung. Cyanosis can be a very late indicator of hypoxia, but it is not a reliable sign of hypoxia. The other signs listed may represent only a temporary hypoxia.

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 patient with pulmonary edema would be expected to have crackles in the lung bases, and possible wheezes. Egophony may occur in patients diagnosed with pleural effusion. Absent breath sounds occurs in pneumothorax. Bronchial breath sounds occur in consolidation, such as pneumonia.

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

Producing sound The larynx, or voice box, is a cartilaginous framework between the pharynx and trachea. Its primary function is to produce sound. While the larynx assists in protecting the lower airway, this is mainly the function of the epiglottis. Facilitating coughing is a secondary function of the larynx. Preventing infection is the main function of the tonsils and adenoids.

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 high ventilation-perfusion rate means that ventilation exceeds perfusion, causing dead space. The alveoli do not have an adequate blood supply for gas exchange to occur. This is characteristic of a variety of disorders, including pulmonary emboli, pulmonary infarction, and cardiogenic shock.

A nurse practitioner diagnosed a patient with an infection in the maxillary sinuses. Select the area that the nurse palpated to make that diagnosis. Above the eyebrows Between the eyes and behind the nose On the cheeks below the eyes Behind the ethmoid sinuses

On the cheeks below the eyes To palpate the maxillary sinuses, the nurse should apply gentle pressure in the cheek area below the eyes, adjacent to the nose.

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 the nurse perform first? Arterial blood gases Pulmonary function test Pulse oximetry Chest x-ray

Pulse oximetry Pulse oximetry is a noninvasive method to determine arterial oxygen saturation. Normal values are 95% and above. Using this diagnostic test first provides rapid information of the client's respiratory system. All other options vary in amount of time and patient participation in determining further information regarding the respiratory system.

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 a dull pain when the catheter is introduced." "I will feel light-headed when the contrast medium is introduced." "I will feel waves of nausea throughout the procedure." "I will feel warm and may have chest pain"

"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 possibility 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.

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 Pleuritic pain from irritation of the parietal pleura is sharp and seems to "catch" on inspiration; patients often describe it as being "like the stabbing of a knife." In carcinoma, the pain may be dull and persistent because the cancer has invaded the chest wall, mediastinum, or spine.

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. Sibilant or hissing or whistling wheezes are continuous musical sounds that can be heard during inspiration and expiration. They result from air passing through narrowed or partially obstructed air passages and are heard in clients with increased secretions. The crackling or grating sounds heard during inspiration or expiration are friction rubs. They occur when the pleural surfaces are inflamed.

Pink, frothy sputum may be an indication of a lung abscess. pulmonary edema. an infection. bronchiectasis.

pulmonary edema. Profuse frothy, pink material, often welling up into the throat, may indicate pulmonary edema. Foul-smelling sputum and bad breath may indicate a lung abscess, bronchiectasis, or an infection caused by fusospirochetal or other anaerobic organisms.

A nurse would question the accuracy of a pulse oximetry evaluation in which of the following conditions? A client receiving oxygen therapy via Venturi mask A client experiencing hypothermia A client sitting in a chair after prolonged bed rest A client on a ventilator with PEEP

A client experiencing hypothermia Pulse oximetry is a noninvasive method of continuously monitoring the oxygen saturation of hemoglobin. The reading is referred to as SpO2. A probe or sensor is attached to the fingertip, forehead, earlobe, or bridge of the nose. Values less than 85% indicate that the tissues are not receiving enough oxygen. SpO2 values obtained by pulse oximetry are unreliable in states of low perfusion such as hypothermia.

Which of the following disease processes cause increased compliance? Emphysema Pulmonary fibrosis Pulmonary edema Acute respiratory distress syndrome

Emphysema High or increased compliance occurs if the lungs have lost their elasticity (cannot return to normal state) and the thorax is overdistended, as in emphysema. Low or decreased compliance occurs if the lungs and thorax are "stiff" (difficult to stretch). Conditions associated with decreased compliance include pneumothorax, hemothorax, pleural effusion, pulmonary edema, atelectasis, pulmonary fibrosis, and acute respiratory distress syndrome (ARDS).

The nurse is admitting a client who just had a bronchoscopy. Which assessment should be the nurse's priority? Medication allergies Swallow reflex Presence of carotid pulse Ability to deep breathe

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.

For which reason does gas exchange decrease in older adults? The alveolar walls become thicker. The alveolar walls contain fewer capillaries. The elasticity of the lungs increases with age. The number of alveoli decreases with age.

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 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 inspiratory and expiratory centers in the medulla oblongata and pons control the rate and depth of ventilation. When injury occurs or increased intracranial pressure results, respirations are slowed. The frontal lobe completes executive functions and cognition. The central sulcus is a fold in the cerebral cortex called the central fissure. The Wernicke's area is the area linked to speech.

What is the difference between respiration and ventilation? Ventilation is the process of gas exchange. Ventilation is the movement of air in and out of the respiratory tract. Ventilation is the process of getting oxygen to the cells. Ventilation is the exchange of gases in the lung.

Ventilation is the movement of air in and out of the respiratory tract. Ventilation is the actual movement of air in and out of the respiratory tract. Respiration is the exchange of oxygen and CO2 between atmospheric air and the blood and between the blood and the cells.

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? Bronchiectasis An infection with pneumococcal pneumonia A lung abscess Bronchitis

An infection with pneumococcal pneumonia Sputum that is rust colored suggests infection with pneumococcal pneumonia. Bronchiectasis and a lung abscess usually are associated with purulent thick and yellow-green sputum. Bronchitis usually yields a small amount of purulent sputum.

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 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 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 While the nurse is assessing for tactile fremitus, the client is asked to repeat "ninety-nine" or "one, two, three," or "eee, eee, eee" as the nurse's hands move down the client's thorax. Vibrations are detected with the palmar surfaces of the fingers and hands, or the ulnar aspect of the extended hands, on the thorax. The hand(s) are moved in sequence down the thorax, and corresponding areas of the thorax are compared. Asking the client to say "one, two, three" while auscultating the lungs is not the proper technique to assess for tactile fremitus. The nurse assesses for anterior respiratory excursion by placing the thumbs along the costal margin of the chest wall and instructing the client to inhale deeply. The nurse assesses for diaphragmatic excursion by instructing the client to take a deep breath and hold it while the diaphragm is percussed.

Which is a deformity of the chest that occurs as a result of overinflation of the lungs? Funnel chest Pigeon chest Barrel chest Kyphoscoliosis

Barrel chest A barrel chest occurs as a result of overinflation of the lungs. The anteroposterior diameter of the thorax increases. Funnel chest occurs when a depression occurs in the lower portion of the sternum, which may result in murmurs. Pigeon chest occurs as a result of displacement of the sternum, resulting in an increase in the anteroposterior diameter. Kyphoscoliosis is characterized by elevation of the scapula and a corresponding S-shaped spine. This deformity limits lung expansion within the thorax.

A client appears to be breathing faster than during the last assessment. Which of the following actions 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. Observing the rate and depth of respiration is an important aspect of a nursing assessment. The normal adult resting respiratory rate is 12 to 18 breaths per minute. Tachypnea is rapid breathing with a rate greater than 24 breaths per minute. An increase in the rate of respirations needs further investigation and must be reported.

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 The client's appearance may give clues to respiratory status. Cyanosis, a bluish coloring of the skin, is a very late indicator of hypoxia. The presence of cyanosis is from decreased unoxygenated hemoglobin. In the presence of a pulmonary condition, cyanosis is assessed by observing the color of the tongue and lips.

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

Diagnosis of peripheral vascular disease Pulse oximetry is a noninvasive method of monitoring oxygen saturation of hemoglobin. A probe is placed on the fingertip, forehead, earlobe, or bridge of nose. Inaccuracy of results may be from anemia, bright lights, shivering, nail polish, or peripheral vascular disease.

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 Airflow is decreased with atelectasis, which is a bronchial obstruction from collapsed lung tissue. If there is an obstruction, there is limited or no gas exchange in this area. Impaired gas exchange is thus the most likely nursing diagnosis with atelectasis.

A client has just undergone bronchoscopy. Which nursing assessment is most important at this time? Level of consciousness Anxiety Swallowing reflex Voice quality

Level of consciousness Following bronchoscopy, level of consciousness is the most important assessment because changes in the client's level of consciousness may alert the nurse to serious neurologic problems. Anxiety, swallowing reflex, and voice quality are important, but don't take precedence at this time.

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? Client can perform incentive spirometry. Lungs are clear on auscultation. Respiratory rate is 12 to 18 breaths per minute. Client reports no chest pain.

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.

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

No tenderness during palpation Sinus assessment involves using the thumbs to apply gentle pressure in an upward fashion at the sinuses. Tenderness suggests inflammation. The sinuses can be inspected by transillumination, where a light is passed through the sinuses. If the light fails to penetrate, the cavity contains fluid.

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 Orthopnea is the inability to breathe easily except when upright. This positioning can mean while in bed and propped with a pillow or sitting in a chair. If a client cannot breathe easily while lying down, there is an element of respiratory distress.

The clinical finding of pink, frothy sputum may be an indication of which condition? Lung abscess Pulmonary edema Infection Bronchiectasis

Pulmonary edema Profuse frothy, pink material, often welling up into the throat, may indicate pulmonary edema. Foul-smelling sputum and bad breath may indicate a lung abscess, bronchiectasis, or an infection caused by fusospirochetal or other anaerobic organisms.

A client with chronic bronchitis is admitted to the health facility. Auscultation of the lungs reveals low-pitched, rumbling sounds. What breath sound should the nurse document? Rales Venous hum Rhonchi Bronchovesicular

Rhonchi Rhonchi or sonorous wheezes are deep, low-pitched, rumbling sounds heard usually on expiration. The etiology of rhonchi is associated with chronic bronchitis. Rales or crackles are soft, high-pitched sounds. A venous hum is a blood flow humming sound. Bronchovesicular sound is an intermediate pitch with expiration and inspiration.

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 If possible, it is best to place the client upright or sitting on the edge of the bed with the feet supported and arms and head on a padded over-the-bed table. Other positions in which the client could be placed include straddling a chair with arms and head resting on the back of the chair, or lying on the unaffected side with the head of the bed elevated 30 to 45 degrees (if the client is unable to assume a sitting position).

The nurse receives an order to obtain a sputum sample from a client with hemoptysis. When advising the client of the physician's order, the client states not being able to produce sputum. Which suggestion, offered by the nurse, is helpful in producing the sputum sample? Tickle the back of the throat to produce the gag reflex. Drink 8 oz of water to thin the secretions for expectoration. Use the secretions present in the oral cavity. Take deep breaths and cough forcefully.

Take deep breaths and cough forcefully. Taking deep breaths moves air around the sputum and coughing forcefully moves the sputum up the respiratory tract. Once in the pharynx, the sputum can be expectorated into a specimen container. Producing a gag reflex elicits stomach contents and not respiratory sputum. Dilute and thinned secretions are not helpful in aiding expectoration. A sputum culture is not a component of oral secretions.

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. When completing a procedure which sends a scope down the throat, the gag reflex is anesthetized to reduce discomfort. Upon returning to the nursing unit, the gag reflex must be assessed before providing any food or fluids to the client. The client may need assistance following the procedure for activity and ambulation but this is not restricted in the post procedure period.

A nurse is assessing a client's respiratory system. Which alveolar cells secrete surfactant to reduce lung surface tension? Type I Type II Macrophages Type IV

Type 2 There are three types of alveolar cells. Type I and type II cells make up the alveolar epithelium. Type I cells account for 95% of the alveolar surface area and serve as a barrier between the air and the alveolar surface; type II cells account for only 5% of this area but are responsible for producing type I cells and surfactant. Surfactant reduces surface tension, thereby improving overall lung function. Alveolar macrophages, the third type of alveolar cells, are phagocytic cells that ingest foreign matter and, as a result, provide an important defense mechanism. Type IV is not a category of alveolar 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 There are three types of alveolar cells. Type I and type II cells make up the alveolar epithelium. Type I cells account for 95% of the alveolar surface area and serve as a barrier between the air and the alveolar surface; type II cells account for only 5% of this area, but are responsible for producing type I cells and surfactant. Surfactant reduces surface tension, thereby improving overall lung function. Alveolar macrophages, the third type of alveolar cells, are phagocytic cells that ingest foreign matter and, as a result, provide an important defense mechanism. The epithelium of the alveoli does not contain Type IV cells.