chapter 20 prepu
The nurse is calculating the patient's smoking history in pack-years. The patient has recently been diagnosed with malignant lung cancer. The patient states he has been smoking two packs of cigarettes a day for the past 11 years. The nurse correctly documents the patient's pack-years as which of the following? 10 11 5 22
22
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? Asthma Pneumothorax Acute respiratory obstruction Adult respiratory distress syndrome
Asthma 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 is caring for an adolescent client injured in a snowboarding accident. The client has a head injury, a fractured right rib, and various abrasions and contusions. The client has a blood pressure of 142/88 mm Hg, pulse of 102 beats/minute, and respirations of 26 breaths/minute. Which laboratory test best provides data on a potential impairment in ventilation? Blood gases Serum alkaline phosphate Blood chemistry Complete blood count
Blood gases
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? Respiratory rate is 12 to 18 breaths per minute. Client reports no chest pain. Lungs are clear on auscultation . Client can perform incentive spirometry.
Lungs are clear on auscultation
A physician has ordered that a client with suspected lung cancer undergo magnetic resonance imaging (MRI). The nurse explains the benefits of this study to the client. Included in teaching would be which of the following regarding the MRI? Tumor densities can be seen with radiolucent images. Narrow-beam x-ray can scan successive lung layers. Lung blood flow can be viewed after a radiopaque agent is injected. MRI can view soft tissues and can help stage cancers.
MRI can view soft tissues and can help stage cancers.
Upon palpation of the sinus area, what would the nurse identify as a normal finding? Tenderness during palpation Pain sensation behind the eyes No sensation during palpation Light not going through the sinus cavity
No sensation during palpation
A nurse practitioner diagnosed a patient with an infection in the maxillary sinuses. Select the area that the nurse palpated to make that diagnosis. Between the eyes and behind the nose Above the eyebrows Behind the ethmoid sinuses On the cheeks below the eyes
On the cheeks below the eyes
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? Lung infarction Pleurisy Bronchogenic carcinoma Bacterial pneumonia
Pleurisy
What finding by the nurse may indicate that the patient has chronic hypoxia? Peripheral edema Clubbing of the fingers Crackles Cyanosis
Clubbing of the fingers
The nurse is instructing the client on the normal sensations, which can occur when contrast medium is infused during pulmonary angiography. Which statement, made by the client, demonstrates an understanding? "I will feel warm and an urge to cough." "I will feel a dull pain when the catheter is introduced." "I will feel waves of nausea throughout the procedure." "I will feel light-headed when the contrast medium is introduced."
"I will feel warm and an urge to cough."
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? 95% 75% 80% 40%
95%
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? Flushed feeling in the client Raised temperature in the affected limb Excessive capillary refill Absent distal pulses
Absent distal pulses 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 caring for a patient diagnosed with pneumonia. The nurse will assess the patient for tactile fremitus by completing which of the following? Instructing the patient 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 patient to inhale deeply A sking the patient to say "one, two, three" while auscultating the lungs Asking the patient to repeat "ninety-nine" as the nurse's hands move down the patient's thorax
Asking the patient to repeat "ninety-nine" as the nurse's hands move down the patient's thorax
The nurse is caring for a patient with recurrent hemoptysis who has undergone a bronchoscopy. Immediately following the procedure, the nurse should complete which of the following? Instruct the patient that bed rest must be maintained for 2 hours. Offer the patient ice chips. Ensure the patient remains moderately sedated to decrease anxiety. Assess the patient for a cough reflex.
Assess the patient for a cough reflex. After the procedure, the patient must take nothing by mouth until the cough reflex returns, because the preoperative sedation and local anesthesia impair the protective laryngeal reflex and swallowing. Once the patient demonstrates a cough reflex, the nurse may offer ice chips and eventually fluids. The patient is sedated during the procedure, not afterward. The patient is not required to maintain bed rest following the procedure.
A client presents to the emergency department with fluid overload. The nurse is concerned about fluid accumulation in the lungs. On which of the following areas would the nurse focus the lung assessment? Posterior bronchioles Anterior bronchial tree Right lower lobe Bilateral lower lobes
Bilateral lower lobes Assessment of the anterior and posterior lungs is part of the nurse's routine evaluation. Fluid overload should be monitored for accumluation in the lungs. Dependent areas must be assessed for breath sounds. The bases of the lungs are considered dependent areas. Fluid in the lungs will usually produce the adventitious sounds of crackles, most frequently auscultated in the bilateral bases of the lungs
A client appears to be breathing faster than during the last assessment. Which of the following interventions should the nurse perform? Inquire if there have been any stressful visitors. Assess the radial pulse. Assist the client to lie down. Count the rate of respirations.
Count the rate of respirations.
The nurse is assessing the lungs of a patient diagnosed with pulmonary edema. Which of the following would be expected upon auscultation? Bronchial breath sounds Absent breath sounds Egophony Crackles at lung bases
Crackles at lung bases
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? Cyanosis Confusion Dyspnea Restlessness
Cyanosis
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 Crackles Cyanosis Son's statement
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? Reduced lighting in the room Increased temperature of the room Diagnosis of peripheral vascular disease Placement of the probe on an earlobe
Diagnosis of peripheral vascular disease
Which of the following clinical manifestations should a nurse monitor for during a pulmonary angiography, which indicates an allergic reaction to the contrast medium? Urge to cough Difficulty in breathing Absent distal pulses Hematoma
Difficulty in breathing
Question 4 of 5 A client receiving a unit of packed red blood cells (PRBCs) has been prescribed morphine 1 mg intravenously now for pain. What is the best method for the nurse to administer the morphine? Inject the morphine into a distal port on the blood tubing. Administer the morphine into the closest tubing port to the client for fast delivery. Disconnect the blood tubing, flush with normal saline, and administer morphine. Add the morphine to the blood to be slowly administered.
Disconnect the blood tubing, flush with normal saline, and administer morphine. Never add medications to blood or blood products. The transfusion must be temporarily stopped in order to administer the morphine.
A nurse is preparing a client for bronchoscopy. Which instruction should the nurse give to the client? Don't walk. Don't eat. Don't talk. Don't cough.
Don't eat.
A client arrives at the physician's office stating dyspnea; a productive cough for thick, green sputum; respirations of 28 breaths/minute, and a temperature of 102.8° F. The nurse auscultates the lung fields, which reveal poor air exchange in the right middle lobe. The nurse suspects a right middle lobe pneumonia. To be consistent with this anticipated diagnosis, which sound, heard over the chest wall when percussing, is anticipated? Tympanic Resonant Hyperresonant Dull
Dull A dull percussed sound, heard over the chest wall, is indicative of little or no air movement in that area of the lung. Lung consolidation such as in pneumonia or fluid accumulation produces the dull sound. A tympanic sound is a high-pitched sound commonly heard over the stomach or bowel. A resonant sound is noted over normal lung tissue. A hyper resonant sound is an abnormal lower pitched sound that occurs when free air exists in disease processes such as pneumothorax.
A 6-month-old male client and his elder brother, a 3-year-old male, are being seen in the pediatric clinic for their third middle ear infection of the winter. The mother reports they develop an upper respiratory infection and an ear infection seems quick to follow. What contributes to this event? Oropharynx Genetics Epiglottis Eustachian tubes
Eustachian tubes
A nurse is obtaining a health history from a client who reports hemoptysis for the past 2 months. The client reports occasional dyspnea. Which imaging study, ordered by the physician, will view the thoracic cavity while in motion? Chest x-ray Fluoroscopy Magnetic resonance imaging (MRI) Computed tomography (CT) scan
Fluoroscopy
On arrival at the intensive care unit, a critically ill client suffers respiratory arrest and is placed on mechanical ventilation. The physician orders pulse oximetry to monitor the client's arterial oxygen saturation (SaO2) noninvasively. Which vital sign abnormality may alter pulse oximetry values? Tachypnea Fever Tachycardia Hypotension
Hypotension
A nurse is concerned that a client may develop postoperative atelectasis. Which nursing diagnosis would be most appropriate if this complication occurs? Decreased cardiac output Ineffective airway clearance Impaired spontaneous ventilation Impaired gas exchange
Impaired gas exchange
he nursing instructor is talking with senior nursing students about diagnostic procedures used in respiratory diseases. The instructor discusses thoracentesis, defining it as a procedure performed for diagnostic purposes or to aspirate accumulated excess fluid or air from the pleural space. What would the instructor tell the students purulent fluid indicates? Heart failure Infection Cancer Inflammation
Infection A small amount of fluid lies between the visceral and parietal pleurae. When excess fluid or air accumulates, the physician aspirates it from the pleural space by inserting a needle into the chest wall. This procedure, called thoracentesis, is performed with local anesthesia. Thoracentesis also may be used to obtain a sample of pleural fluid or a biopsy specimen from the pleural wall for diagnostic purposes such as a culture, sensitivity, or microscopic examination. Purulent fluid is the recommended diagnosis for infection. Serous fluid may be associated with cancer, inflammatory conditions, or heart failure.
Which respiratory volume is the maximum volume of air that can be inhaled after maximal expiration? Expiratory reserve volume Tidal volume Inspiratory reserve volume Residual volume
Inspiratory reserve volume
Question 5 of 5 The nurse should notify the healthcare provider before administering fresh frozen plasma (FFP) based on which assessment finding? Strong pedal pulses Jugular venous distention White sclera Absence of tenting skin turgor
Jugular venous distention During the pre-transfusion assessment, the nurse should carefully inspect for any signs of cardiac failure, such as jugular venous distention. The sclera should be examined for icterus; white is an expected finding. Weak pedal pulses would be a sign of cardiac failure. Tenting skin turgor is a sign of dehydration; low vascular volume would be a cause for transfusion, not a contraindication.
A patient diagnosed with diabetic ketoacidosis would be expected to have which type of respiratory pattern? Kussmaul respirations Biot's respirations Apnea Cheyne-Stokes
Kussmaul respirations
When assessing a client, which adaptation indicates the presence of respiratory distress? Orthopnea Respiratory rate of 14 breaths per minute Productive cough Sore throat
Orthopnea
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.) Previous history of smoking Social support Previous history of lung disease in the patient or family Financial ability to pay the bill Occupational and environmental influences
Previous history of smoking Previous history of lung disease in the patient or family Occupational and environmental influences
A 53-year-old client sees the physician because he has had laryngitis for 2 weeks. After a thorough examination, the doctor orders medications and instructs the client to follow-up in 1 week if his voice has not improved. What is the primary function of the larynx? Producing sound Facilitating coughing Preventing infection Protecting the lower airway from foreign objects
Producing sound
patient exhibited signs of an altered ventilation-perfusion ratio. The nurse is aware that adequate ventilation but impaired perfusion exists when the patient has which of the following conditions? Tumor Infective process Pulmonary embolism Atelectasis
Pulmonary embolism
A nurse is reviewing arterial blood gas results on an assigned client. The pH is 7.32 with PCO2 of 49 mm Hg and a HCO3−of 28 mEq/L. The nurse reports to the physician which finding? Metabolic acidosis Respiratory alkalosis Metabolic alkalosis Respiratory acidosis
Respiratory acidosis Respiratory acidosis would be reported to the physician citing the lab values. Analysis of the blood gases reveals that the client is acidotic with a pH under 7.35. Also noted is the PCO2above the normal range of 30 to 40 mm Hg. The HCO3− is slightly elevated because the normal level is 22 to 26 mEq/L
The nurse is caring for a client with chronic obstructive pulmonary disease. The client calls the doctor and states having difficulty breathing and overall feeling fatigued. The nurse realizes that this client is at high risk for which condition? Respiratory alkalosis Respiratory acidosis Metabolic acidosis Metabolic alkalosis
Respiratory acidosis Respiratory acidosis occurs when the body is unable to blow off CO2 due to the hypoventilation of disease processes such as COPD. An increase in blood carbon dioxide concentration occurs and a decreased pH causing acidosis. Respiratory alkalosis is a decrease in acidity of the blood and often caused by hyperventilation. Metabolic acidosis/alkalosis are disorders that affect the bicarbonate.
A nurse is reviewing arterial blood gas results on an assigned client. The pH is 7.32 with PCO2 of 49 mm Hg and a HCO3−of 28 mEq/L. The nurse reports to the physician which finding? Respiratory acidosis Metabolic alkalosis Metabolic acidosis Respiratory alkalosis
Respiratory acidosis Respiratory acidosis would be reported to the physician citing the lab values. Analysis of the blood gases reveals that the client is acidotic with a pH under 7.35. Also noted is the PCO2above the normal range of 30 to 40 mm Hg. The HCO3− is slightly elevated because the normal level is 22 to 26 mEq/L.
A client with chronic bronchitis is admitted to the health facility. Auscultation of the lungs reveals low-pitched, rumbling sounds. Which of the following describes these sounds? Rhonchi Crackles Bronchial Pleural friction rub
Rhonchi Rhonchi are deep, low-pitched, rumbling sounds heard usually on expiration. The etiology of rhonchi is associated with chronic bronchitis.
The nurse is admitting a client who just had a bronchoscopy. Which assessment should be the nurse's priority? Medication allergies Ability to deep breathe Swallow reflex Presence of carotid pulse
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.
Which of the following results in decreased gas exchange in older adults? The number of alveoli decreases with age. The alveolar walls become thicker. The alveolar walls contain fewer capillaries. The elasticity of the lungs increases with age.
The alveolar walls contain fewer capillaries
The nurse answers the call light of a male patient. The patient is complaining of an irritating tickling sensation in the throat, a salty taste, and a burning sensation in the chest. Upon further assessment, the nurse notes a tissue with bright red, frothy blood at the bedside. The nurse can assume the source of the blood is likely from which of the following? The rectum The stomach The lungs The nose
The lungs Blood from the lung is usually bright red, frothy, and mixed with sputum. Initial symptoms include a tickling sensation in the throat, a salty taste, a burning or bubbling sensation in the chest, and perhaps chest pain, in which case the patient tends to splint the bleeding side. This blood has an alkaline pH (>7.0). Blood from the stomach is vomited rather than expectorated, may be mixed with food, and is usually much darker; often referred to as "coffee ground emesis." This blood has an acid pH (<<7.0). Bloody sputum from the nose or the nasopharynx is usually preceded by considerable sniffing, with blood possibly appearing in the nose.
The client is returning from the operating room following a broncho scopy. Which action, performed by the nursing assistant, would the nurse stop if began prior to nursing assessment? The nursing assistant is asking a question requiring a verbal response. The nursing assistant is assisting the client to the side of the bed to use a urinal. The nursing assistant is assisting the client to a semi-Fowler's position. The nursing assistant is pouring a glass of water to wet the client's mouth.
The nursing assistant is pouring a glass of water to wet the client's mouth.
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 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 are heard in clients with decreased secretions. They result from air passing through widened air passages. They occur when the pleural surfaces are inflamed. They can be heard during inspiration and expiration.
They can be heard during inspiration and expiration.
Which of the following alveolar cells secrete surfactant? Type I Type IV Type III Type II
Type II
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? Ventilation matches perfusion. Ventilation exceeds perfusion. There is an absence of perfusion and ventilation. Perfusion exceeds ventilation.
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.
What is the difference between respiration and ventilation? 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 process of gas exchange.
Ventilation is the movement of air in and out of the respiratory tract.
The nursing instructor is teaching a pre-nursing pathophysiology class. The class is covering the respiratory system. The instructor explains that the respiratory system is comprised of both the upper and lower respiratory system. The nose is part of the upper respiratory system. The instructor continues to explain that the nasal cavities have a vascular and ciliated mucous lining. What is the purpose of the vascular and ciliated mucous lining of the nasal cavities? Warm and humidify inspired air Move mucus to the back of the throat Cool and dry expired air Moisten and filter expired air
Warm and humidify inspired air
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? Pleural friction rub Crackles Rhonchi Wheezes
Wheezes
A nurse is preparing a client with a pleural effusion for a thoracentesis. The nurse should: raise the arm on the side of the client's body on which the physician will perform the thoracentesis. place the client supine in the bed, which is flat. raise the head of the bed to a high Fowler's position. assist the client to a sitting position on the edge of the bed, leaning over the bedside table.
assist the client to a sitting position on the edge of the bed, leaning over the bedside table. A physician usually performs a thoracentesis when the client is sitting in a chair or on the edge of the bed, with the legs supported and the arms folded and resting on a pillow or on the bedside table. Raising an arm, lying supine, or raising the head of the bed won't allow the physician to easily access the thoracic cavity.
Pink frothy sputum may be an indication of an infection. pulmonary edema. bronchiectasis. a lung abscess.
pulmonary edema.
The amount of air inspired and expired with each breath is called: vital capacity. tidal volume. residual volume. dead-space volume.
tidal volume.