Chapter 20: Assessment of Respiratory Function NCLEX

c (Fluoroscopy)

A physician wants a study of diaphragmatic motion because the suspected pathology. What does the nurse anticipate the physician will most likely order? a. Barium swallow b. Bronchogram c. Fluoroscopy d. Tomogram

b (Emphysema)

During a pre-admission assessment, for what diagnosis would the nurse expect to find increased tactile fremitus and hyperresonant percussion sounds? a. Bronchitis b. Emphysema c. Atelectasis d. Pulmonary edema

a (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? a. Cyanosis b. Dyspnea c. Restlessness d. Confusion

a, b, c (A mask will be placed over the nose and mouth during the test, The patient will be expected to lie under the camera, The imaging time will amount to 20 to 40 minutes)

The nurse is instructing a patient who is scheduled for perfusion lung scan. What should be included in the information about the procedure? (select all that apply.) a. A mask will be placed over the nose and mouth during the test b. The patient will be expected to lie under the camera c. The imaging time will amount to 20 to 40 minutes d. The patient will be expected to be NPO for 12 hours prior to the procedure e. An injection will be placed into the lung during the procedure.

c (Wheezes)

The nurse is performing chest auscultation for a patient with asthma. How does the nurse describe the high-pitched, sibilant, musical sounds that are heard? a. Rales b. Crackles c. Wheezes d. Rhonchi

b (PaCO2)

The nurse is reviewing the blood gas results for a patient with pneumonia. What arterial blood gas measurement best reflects the adequacy of alveolar ventilation? a. PaO2 b. PaCO2 c. pH d. SaO2

c, d, e (Decreased gag reflex, Increased presence of collagen in alveolar walls, Decreased presence of mucus)

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) a. Decreased alveolar duct diameter b. Increased presence of mucus c. Decreased gag reflex d. Increased presence of collagen in alveolar walls e. Decreased presence of mucus

c (Ventilation exceeds perfusion)

A nurse caring for a patient with a pulmonary embolism understands that a high ventilation-perfusion ratio may exist. What does the is mean for the patient? a. Perfusion exceeds ventilation b. There is an absence of perfusion and ventilation c. Ventilation exceeds perfusion d. Ventilation matches perfusion

d (95 mm Hg)

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? a. 40 mm Hg b. 75 mm Hg c. 80 mm Hg d. 95 mm Hg

d (Pleurisy)

A patient comes to the emergency department complaining of a knifelike pain when taking deep breath. What does this type of pain likely indicate to the nurse? a. Bacterial pneumonia b. Bronchogenic carcinoma c. Lung infarction d. Pleurisy

a (Frontal)

A patient with sinus congestion complains of discomfort when the nurse is palpating the supraorbital ridges. The nurse knows that the patient is referring to which sinus? a. Frontal b. Ethmoidal c. Maxillary d. Sphenoidal

c (Collapsed alveoli)

The nurse auscultates crackles in a patient with a respiratory disorder. With what disorder would crackles be commonly heard? a. Asthma b. Bronchospasm c. Collapsed alveoli d. Pulmonary edema

a (Barrel chest)

The nurse inspects the thorax of a patient with advanced emphysema. What does the nurse expect the chest configuration to be for this patient? a. Barrel chest b. Funnel chest c. Kyphoscoliosis d. Pigeon chest

b (Cyanosis)

The nurse is assessing a patient in respiratory failure. What finding is a late indicator of hypoxia? a. Clubbing of fingers b. Cyanosis c. Crackles d. Restlessness

a, b, d (Initially, clear the nose and throat, Take a few deep breaths before coughing, Use diaphragmatic contractions to aid in the expulsion of sputum)

The nurse is instructing the patient on the collection of a sputum specimen. What should be included in the instructions? a. Initially, clear the nose and throat b. Spit surface mucus and saliva into a sterile specimen container c. Take a few deep breaths before coughing d. Use diaphragmatic contractions to aid in the expulsion of sputum e. Rinse with mouthwash prior to providing the specimen

a (Angiotensin converting enzyme (ACE) inhibitors)

The nurse is interviewing a patient who says he has dragged, irritating cough that is not "bringing up anything". What medication should the nurse question the patient about taking? a. Angiotensin converting enzyme (ACE) inhibitors b. Aspirin c. Bronchodialators d. Cardiac glycosides

b (Orthopnea)

The nurse is performing an assessment for a patient with congestive heart failure. The nurse asked if the patient has difficulty breathing in any position other than upright. What is the nurse referring to? a. Dyspnea b. Orthopnea c. Tachypnea d. Bradypnea

d (Biot's respirations)

The nurse is performing in the sentiment of a patient who arrived in the emergency department with a barbiturate overdose. The respirations are normal 3 to 4 breaths followed by a 60-second period apnea. How does the nurse document the respirations? a. Cheyne-Stokes b. Tachypnea c. Bradypnea d. Biot's respirations

c, d, e (Previous history of lung disease in the patient or family, Occupational and environmental influences, Previous history of smoking)

The nurse is taking a respiratory history for a patient who has come into the clinic with a chronic cough. What information should the nurse obtain from this patient? (select all that apply) a. Financial ability to pay the bill b. Social support c. Previous history of lung disease in the patient or family d. Occupational and environmental influences e. Previous history of smoking

c (Clubbing of the fingers)

What finding by the nurse May indicate that patient has chronic hypoxia? a. Crackles b. Peripheral edema c. Clubbing of the fingers d. Cyanosis