Ch. 24
Normal PaO2 levels
80-100 mmHg
While responding to questions in a health history, the client reports that he usually expectorates about 2 ounces of thin, clear, colorless sputum daily, usually on getting up in the morning. What is the nurse's best action related to this finding? A. Document the report as the only action. B. Arrange for the client to have tuberculosis testing. C. Collect a sputum specimen for laboratory analysis. D. Alert the primary health care provider about this funding.
A
The nurse has just received report on a group of clients. Which client is the nurse's first priority? A 40 year old admitted 3 hours ago for a scheduled thoracentesis in 30 minutes. A 55 year old with bronchogenic lung cancer who returned from bronchoscopy 4 hours ago. A 30 year old with acute asthma who has an oxygen saturation of 89% by pulse oximetry. A 68 year old with pleural effusion who has decreased breath sounds at the right base.
A 30 year old with acute asthma who has an oxygen saturation of 89% by pulse oximetry. The client in need of the most immediate assessment is the one with acute asthma with an oxygen saturation of 89% by pulse oximetry. An oxygen saturation level less than 91% indicates hypoxemia and instability requiring immediate assessment and intervention to improve blood and tissue oxygenation.The client who is scheduled for a thoracentesis will be able to receive teaching and will have the opportunity to ask questions and have them answered before the procedure is performed. There is no evidence the client who had a bronchoscopy 3 hours ago is unstable and therefore does not require attention at this moment. It would not be unusual to have diminished breath sounds at the base of the lung of the client with pleural effusion.
I PREPARE
A tool used to assess PME exposure Investigate Present work Residence Environment Past work Activities Resources and referrals Educate
What is the nurse's interpretation of a 50-year-old client's respiratory assessment findings when hearing bronchial breath sounds over the left lower lobe and noting decreased fremitus and dullness to percussion in the same area? Obstruction of the larger airways Normal physical exam for a 50 year old An area of increased density Subcutaneous emphysema
An area of increased density Peripheral bronchial breath sounds are abnormal and can indicate atelectasis, tumor, or pneumonia. Decreased fremitus and dullness to percussion may indicate pleural effusion, which is more dense than air.Bronchial breath sounds are normally heard only over the large airways in patients of any age, not in the periphery. An obstructed airway would have reduced bronchial breath sounds, and they would not be present in the periphery. Subcutaneous emphysema is a condition in which air is trapped within or beneath the skin. It is felt and heard as a "crackling" in the skin and subcutaneous tissues, not within any part of the respiratory tract.
The 5 As Model for Treating Tobacco Use and Dependence by Nurses
Ask about use Advise to quit Assess willingness to attempt to quit Assist in quitting attempt Arrange a follow-up
What is the most relevant technique for the nurse to use when assessing a client for dyspnea? Checking oxygen saturation by pulse oximetry Observing the client's rate, depth, and ease of inhalation and exhalation Comparing previous respiratory assessment information with current data Asking the client about whether any breathlessness is present
Asking the client about whether any breathlessness is present Dyspnea, difficulty in breathing or breathlessness, is a subjective perception and varies among clients. Thus, only the client can rate his or her level of dyspnea.The other measures listed for assessment of respiratory status and adequacy of ventilation and oxygenation are objective measures.
When these changes happen in older adults, what are some good nursing implications? Body's response to hypoxia and hypercarbia decreases.
Assess for subtle manifestations of hypoxia to prevent complications.
When these changes happen in older adults, what are some good nursing implications? Vascular resistance to blood flow through pulmonary vascular system increases. Pulmonary capillary blood volume decreases. Risk for hypoxia increases.
Assess patient's level of consciousness and cognition because hypoxia from acute respiratory conditions can cause the patient to become confused.
The nurse assessing an 88-year-old client notices a severe kyphosis that curves the client's spine to the right and bends her forward. Which change in respiratory function does the nurse expect as a result of this age-related change? A. Decreased gas exchange as a result of reduced airway elasticity B. Decreased gas exchange as a result of ineffective chest movement C. Reduced pulmonary perfusion as a result of decreased alveolar diffusion capacity D. Reduced pulmonary perfusion as a result of decreased blood return to the right atrium
B. Decreased gas exchange as a result of ineffective chest movement
Why are the terminal bronchioles more prone to collapse than are the other airways? Select all that apply. A. The cartilage is an incomplete C shape rather than a true ring. B. The mucous membrane lining contains minimal active cilia. C. Lung elastic recoil is the only force that keeps them patent. D. Their walls are too thick to permit gas exchange. E. They are surrounded by capillaries. F. The lumens have a small diameter. G. Their walls contain no cartilage.
C. Lung elastic recoil is the only force that keeps them patent. F. The lumens have a small diameter. G. Their walls contain no cartilage.
When assessing the client 2 hours after a thoracentesis, the nurse notes the skin around the puncture site is swollen and a crackling is felt and heard when pressure is applied to the area. What is the nurse's best action? A. Assess the client's SPO 2 levels at two separate sites. B. Obtain a prescription to culture the site. C. Document the finding as the only action. D. Notify the respiratory health care provider.
D. Notify the respiratory health care provider.
The nurse is assessing the respiratory status of the client after a thoracentesis has been performed. The nurse would become concerned with which assessment finding? Equal bilateral chest expansion Respiratory rate of 22 breaths per minute Diminished breath sounds on the affected side Few scattered wheezes, unchanged from baseline
Diminished breath sounds on the affected side After thoracentesis, the nurse assesses vital signs and breath sounds. The nurse especially notes increased respiratory rates, dyspnea, retractions, diminished breath sounds, or cyanosis, which could indicate pneumothorax. Any of these manifestations should be reported to the primary health care provider. Options 1 and 2 are normal findings. Option 4 indicates a finding that is unchanged from the baseline.
When these changes happen in older adults, what are some good nursing implications? Anteroposterior diameter increases. Thorax becomes shorter. Progressive kyphoscoliosis occurs. Chest wall compliance (elasticity) decreases. Mobility of chest wall may decrease.
Discuss the normal changes of aging to help reduce anxiety about changes that occur. Discuss the need for increased rest periods during exercise because exercise tolerance decreases with age.
Which teaching point is most important for the nurse to emphasize for a client who is scheduled to undergo pulmonary function testing (PFT)? Avoid strenuous physical activity for 24 hours before the procedure. Use your bronchodilating inhaler right before arriving for the procedure. Do not smoke for 6 hours before the test. Eat only clear liquids for 12 hours before the procedure.
Do not smoke for 6 hours before the test. The essential teaching point for a client being prepared for a PFT is to make sure that the client does not smoke for 6 hours before the test. Smoking can alter parts of the PFT (diffusing capacity [DLCO]), yielding inaccurate results.Administering bronchodilators is not indicated for PFT, but they may be withheld for 4 to 6 hours before the test. Encouraging fluid intake does not have an effect on PFT testing. Supplemental oxygen is not required and will alter the results of PFT. However, oxygen may be given if the client develops distress during testing.
For which problem does the nurse assess the client who cannot breathe through the nose because of a severe septal deviation? Difficulty swallowing Dry respiratory tract membranes Development of nasal polyps Frequent episodes of tonsillitis
Dry respiratory tract membranes When inspired air passes through the nose, it is filtered, warmed, and humidified. When a person is unable to breathe through the nose because of an anatomical obstruction, he or she is at risk for excessive drying of the respiratory mucous membranes. This anatomical problem does not influence the development of tonsillitis or difficulty swallowing. Nasal polyps can contribute to nasal obstruction but is not caused by a septal deviation.
When these changes happen in older adults, what are some good nursing implications? Osteoporosis is possible, leading to chest wall abnormalities.
Encourage adequate calcium intake (especially during a woman's premenopause phase) to help prevent or reduce later osteoporosis.
When these changes happen in older adults, what are some good nursing implications? Effectiveness of the cilia decreases. Immunoglobulin A decreases. Alveolar macrophages are altered. Respiratory muscle strength, especially the diaphragm and the intercostals, decreases.
Encourage pulmonary hygiene and help patient actively maintain health and fitness to promote maximal functioning of the respiratory system and prevent respiratory illnesses.
When these changes happen in older adults, what are some good nursing implications? Alveolar surface area decreases. Diffusion capacity decreases. Elastic recoil decreases. Bronchioles and alveolar ducts dilate. Ability to cough decreases. Airways close early.
Encourage vigorous pulmonary hygiene (i.e., encourage patient to turn, cough, and deep breathe) and use of incentive spirometry, especially if he or she is confined to bed or has had surgery to reduce the risk for infectious respiratory or mechanical complications. Encourage upright position to minimize ventilation-perfusion mismatching.
What is the most common cause of chronic respiratory problems and physical limitations.
Exposure to inhalation irritants, especially to cigarette smoke
How will the nurse document the client's respiratory assessment findings on auscultation that are heard as popping, discontinuous, high-pitched sounds at the end of exhalation? Coarse crackles Rhonchi Wheezes Fine crackles
Fine crackles Fine crackles are heard as popping, discontinuous sounds that are high-pitched heard at the end of inhalation. Squeaky, musical continuous sounds heard when the client inhales and exhales are abnormal (adventitious) and described as wheezes. Coarse crackles are a rattling sound. Rhonchi are heard as low-pitched continuous snoring sounds.
When these changes happen in older adults, what are some good nursing implications? Muscles atrophy. Vocal cords become slack. Laryngeal muscles lose elasticity, and airways lose cartilage.
Have face-to-face conversations with patient when possible because the patient's voice may be soft and difficult to understand.
When these changes happen in older adults, what are some good nursing implications? Residual volume increases. Vital capacity decreases. Efficiency of oxygen and carbon dioxide exchange decreases. Elasticity decreases.
Include inspection, palpation, percussion, and auscultation in lung assessments to detect normal age-related changes. Help patient actively maintain health and fitness to keep losses in respiratory functioning to a minimum. Assess patient's respirations for abnormal breathing patterns, such as Cheyne-Stokes, which can occur in older adults without pathology . Encourage frequent oral hygiene to aid in the removal of secretions.
Which sign or symptom will the nurse report immediately to the pulmonary health care provider to prevent harm for a client who had a percutaneous lung biopsy 2 hours ago? Bruising at the puncture site Lateral displacement of the trachea Oxygen saturation of 97% Pink-tinged sputum
Lateral displacement of the trachea The trachea should always be midline. Lateral displacement after a percutaneous lung biopsy is associated with complications, especially pneumothorax, which requires immediate intervention.
Normal RBC count
Male: 4.7-6.1 Female: 4.2-5.4 Children: 4.0-5.5
Which action will the nurse safely assign to an experienced assistive personnel (AP) to perform with a client who returned an hour ago to the medical-surgical unit after a bronchoscopy? Offering clear liquids when gag reflex returns Determining level of consciousness Assessing breath sounds Monitoring blood pressure and pulse
Monitoring blood pressure and pulse The best nursing action for the nurse to assign to the experienced AP is monitoring blood pressure and pulse. An experienced AP would have experience in taking client vital signs after procedures requiring conscious sedation or anesthesia.Evaluating breath sounds, gag reflex, and determining level of consciousness are considered nursing assessments and require the skill and knowledge of a higher-level provider or professional nurse.
Smoking cessation drugs
OTC: transdermal patches, gum, lozenges (risk of stroke or HA if pt smokes while using this) Prescription: nasal sprays, inhalers
What is the nurse's best first action on finding the client's oxygen saturation by pulse oximetry on the finger is 84%? Apply supplemental oxygen by mask or nasal cannula. Notify the Rapid Response Team immediately. Assess the client's cognitive function. Recheck the value on the forehead.
Recheck the value on the forehead. Although a true low oxygen saturation is an emergency, there are many causes of a low reading using pulse oximetry. The value should be verified immediately before any interventions are implemented.
How will the nurse expect a client's age-related decreased skeletal muscle strength to affect gas exchange? Reduced gas exchange as a result of decreased alveolar surface Reduced gas exchange as a result of longer relaxation of bronchiolar smooth muscles Reduced gas exchange as a result of decreased changes in pressures of the chest cavity Reduced gas exchange as a result of failure of pulmonary circulation to fully perfuse lung tissue
Reduced gas exchange as a result of decreased changes in pressures of the chest cavity Breathing occurs through changes in the size of and pressure within the chest cavity. Contraction and relaxation of chest muscles (and the diaphragm) cause changes in the size and pressure of the chest cavity. When skeletal muscle strength is decreased in these muscles, pressure changes are decreased and less air moves in and out of the lungs. This reduced airflow limits gas exchange at the alveolar-capillary membrane. The alveolar surface itself is not decreased by weaker skeletal muscles, nor does this cause any relaxation of bronchiolar smooth muscle. Weaker skeletal muscles do not directly affect pulmonary circulation.
The nurse is monitoring a client for bradypnea. Which description is characteristic of this respiratory pattern? Regular but abnormally slow Labored and increased in depth and rate Regular but interspersed with periods of apnea Abnormally deep, regular, with increased rate
Regular but abnormally slow Bradypnea is characterized by respirations that are regular but abnormally slow. Hyperpnea is characterized as respirations that are labored and increased in depth and rate. Respirations that cease for a number of seconds are identified as apnea. Kussmaul's respirations are abnormally deep, regular, and increased in rate.
What might you NOTICE in a patient with adequate GAS EXCHANGE and tissue PERFUSION related to respiratory function?
Resp rate (12-20) and HR (60-100) in normal range SaO2 (aka SpO2 OR pulse ox) 95% or > Able to speak 12 straight words, walk and talk without stopping for breath Skin and mucous membranes normal color, finger nails round and pink, fast capillary refill Anterior to posterior diameter of chest about two-thirds the size of the lateral diameter Space between each rib no larger than the breadth of the patient's finger Air movement heard (with stethoscope) in all lobes of both lungs Quiet breathing through nose, out mouth or nose Sputum production minimal, clear or white Muscle development even with no muscle loss on arms and legs Weight proportionate to height; does not appear underweight Red blood cell, hemoglobin, hematocrit, and white blood cell levels within normal limits for age and gender Energy level good, can engage in desired work, recreational, and personal activities
What's the difference between PaO2 and SaO2?
SaO2/SpO2/Pulse Ox is the amount of oxygen bound to hemoglobin PaO2 is the amount of oxygen in arterial blood
Which type of ADL assistance will the nurse plan for a client with long-standing pulmonary problems who has Class IV dyspnea? Dyspnea is minimal and no assistance is required. The client is severely dyspneic at rest and cannot participate in any self-care. The client may complete ADLs without assistance but requires rest periods during performance. The client is severely dyspneic with activity and requires assistance for bathing and dressing.
The client is severely dyspneic with activity and requires assistance for bathing and dressing. Class IV dyspnea occurs during usual activities, such as showering and dressing, and requires assistance from others. Dyspnea is usually not present at rest, but is with minimal exertion.
For which symptoms would a nurse assess a client who worries a thoracentesis earlier today may have caused a pneumothorax? (Select all that apply.) Slowing heart rate Sensation of air hunger Pain at the insertion site Cyanosis of oral mucous membranes Wheezing on inhalation and exhalation Tracheal deviation
Tracheal deviation Sensation of air hunger Cyanosis of oral mucous membranes
A client is experiencing difficulty coping with decreased ability to tolerate activity because of respiratory disease. The home care nurse determines that the client is showing an adaptive response when which behaviors are observed? Has learned to scale back expectations related to activity Increases the use of medication in order to sleep 8 hours nightly Spends most of the day in one room of the home to decrease fatigue Tries to increase ambulation and complete some small tasks each day
Tries to increase ambulation and complete some small tasks each day The client with respiratory disease may have difficulty coping with decreased ability to tolerate activity and social isolation. The client demonstrates adaptive responses by increasing the activity to the highest level possible before symptoms are triggered, using relaxation or other learned coping skills, or enrolling in a pulmonary rehabilitation program. Enhancing self-seclusion, minimizing expectations, and medicating for insomnia are not adaptive responses.
Normal Hemoglobin
Women: 12.0-16.0 g/dL Men: 13.5- 18.0 g/dL
Normal HTC
Women: 36-47% Men: 41-52%
Varincline/Chantix adverse effects
drug interferes with nicotine receptors, manic behavior and hallucinations (teach pt's family to watch for these effects)
Populations with high smoking tendacies
military veterans (>33% compared to non-military veterans) adults w/ GEDs people below the poverty line also for cultural reasons: native Americans and 1st generation Canadians
What is the nurse's best next question after observing that a 60-year-old client's anteroposterior (AP) chest diameter is the same as the lateral chest diameter? "What are your hobbies?" No questions are needed regarding this normal finding. "Do you have any chronic breathing problems?" "How often do you perform aerobic exercise?"
"Do you have any chronic breathing problems?" The normal chest has a lateral diameter that is twice as large as the AP diameter. When the AP diameter approaches or exceeds the lateral diameter, the client is said to have a "barrel" chest. Most commonly, a barrel chest occurs as a result of a long-term chronic airflow limitation problem such as chronic obstructive pulmonary disease or severe chronic asthma. It can also be seen in people who have lived at high altitudes for many years.
The student nurse is listening to a respiratory lecture on wheezing. Which statement by the student nurse indicates that the teaching has been effective? "Wheezing is caused by a grating noise heard on expiration." "Wheezing consists of a gurgling noise heard on expiration." "A creaking noise heard on inspiration indicates wheezing." "Wheezing sounds like a musical or hissing noise heard on inspiration."
"Wheezing sounds like a musical or hissing noise heard on inspiration." A wheeze is a continuous musical or hissing noise that results from the passage of air through a narrowed airway. Wheezes are heard during inspiration or expiration or both. Severe wheezes are audible without a stethoscope. Wheezing is commonly associated with asthma and bronchoconstriction and edema, but foreign body obstruction can also cause airway narrowing and wheezing. Options 1 and 3 describe a pleural friction rub. Option 2 describes rhonchi.
How will the nurse document the pack-year smoking history for a client who reports smoking 3 packs of cigarettes per day for 25 years and then smoking 2 packs per day for the past 20 years? 45-pack-year 90-pack-year 115-pack-year 80-pack-year
115-pack-year Smoking history is documented in pack-years (number of packs per day smoked multiplied by the number of years the client has smoked). 3 packs/day × 25 years = 75-pack-year, plus 2 packs/day × 20 years = 40-pack-year.
Normal total WBC
4,500-10,000 /microliter