Chap 20 : Assessment of Respiratory Function

The nurse working in the radiology clinic is assisting with a pulmonary angiography. The nurse knows that when monitoring clients after a pulmonary angiography, what should the physician be notified about? a) Excessive capillary refill b) Absent distal pulses c) Raised temperature in the affected limb d) Flushed feeling in the client

Absent distal pulses Explanation: When monitoring clients after a pulmonary angiography, nurses must notify the physician about diminished or absent distal pulses, cool skin temperature in the affected limb, and poor capillary refill. When the contrast medium is infused, the client will sense a warm, flushed feeling.

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

Swallow reflex Explanation: 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.

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? a) Adult respiratory distress syndrome b) Acute respiratory obstruction c) Asthma d) Pneumothorax

Asthma Explanation: The presence of both inspiratory and expiratory wheezing usually signifies asthma if the individual does not have heart failure. Sudden dyspnea is an indicator of the other choices.

The nurse inspects the thorax of a patient with advanced emphysema. The nurse expects chest configuration changes consistent with a deformity known as: a) Pigeon chest b) Barrel chest c) Funnel chest d) Kyphoscoliosis

Barrel chest Explanation: Barrel chest occurs as a result of lung hyperinflation, as in emphysema. There is an increase in the anteroposterior diameter of the thorax so that it approximates a 1:1 ratio. In a patient with emphysema, the costal angle will also be greater than 90 degrees.

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? a) Increased temperature of the room b) Diagnosis of peripheral vascular disease c) Reduced lighting in the room d) Placement of the probe on an earlobe

Diagnosis of peripheral vascular disease Explanation: 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.

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? a) Orthopnea b) Bradypnea c) Tachypnea d) Dyspnea

Orthopnea Explanation: Orthopnea (inability to breathe easily except in an upright position) may be found in patients with heart disease and occasionally in patients with chronic obstructive pulmonary disease (COPD). Dyspnea (subjective feeling of difficult or labored breathing, breathlessness, shortness of breath) is a multidimensional symptom common to many pulmonary and cardiac disorders, particularly when there is decreased lung compliance or increased airway resistance. Tachypnea is abnormally rapid respirations. Bradypnea is abnormally slow respirations.

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? a) Central sulcus b) The pons c) Wernicke's area d) The frontal lobe

The pons Explanation: The pons in the brainstem controls rate and depth of respirations. 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.

A client with a suspected pulmonary disorder undergoes pulmonary function tests. To interpret test results accurately, the nurse must be familiar with the terminology used to describe pulmonary functions. Which term refers to the volume of air inhaled or exhaled during each respiratory cycle? a) Tidal volume b) Maximal voluntary ventilation c) Functional residual capacity d) Vital capacity

Tidal volume Explanation: Tidal volume refers to the volume of air inhaled or exhaled during each respiratory cycle when breathing normally. Normal tidal volume ranges from 400 to 700 ml. Vital capacity refers to the total volume of air that can be exhaled during a slow, maximal expiration after maximal inspiration. Functional residual capacity refers to the volume of air remaining in the lungs after a normal expiration. Maximal voluntary ventilation is the greatest volume of air expired in 1 minute with maximal voluntary effort.

While auscultating the lungs of a client with asthma, the nurse hears a continuous, high-pitched whistling sound on expiration. The nurse will document this sound as which of the following? a) Rhonchi b) Pleural friction rub c) Wheezes d) Crackles

Wheezes Explanation: Wheezes, usually heard on expiration, are continuous, musical, high pitched, and whistle-like sounds caused by air passing through narrowed airways. Often, wheezes are associated with asthma

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

tidal volume. Explanation: Tidal volume is the amount of air inspired and expired with each breath. Residual volume is the amount of air remaining in the lungs after forcibly exhaling. Vital capacity is the maximum amount of air that can be moved out of the lungs after maximal inspiration and expiration. Dead-space volume is the amount of air remaining in the upper airways that never reaches the alveoli. In pathologic conditions, dead space may also exist in the lower airways.