Chapter 20: Respiratory Function

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

You are caring for a client admitted with chronic bronchitis. The client is having difficulty breathing, and the family asks you what causes this difficulty. What would be your best response?

"Conditions such as chronic bronchitis cause thickening of the bronchial mucosa so it makes it harder to breathe."

You are the hospice nurse caring for a client with pulmonary fibrosis who wants to die at home. The client is having difficulty breathing. The family asks why it is so hard for the client to breathe. What would be the nurse's best response?

"The fibrosis of the lungs makes the lungs stiff, which makes it harder to breathe.

The nurse is instructing a patient who is scheduled for a perfusion lung scan. What should be included in the information about the procedure? (Select all that apply.)

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.

A client is being seen in the pediatric clinic for a middle ear infection. The client's mother reports that when the client develops an upper respiratory infection, an ear infection seems quick to follow. What contributes to this event?

Eustachian tubes

A patient diagnosed with diabetic ketoacidosis would be expected to have which type of respiratory pattern?

Kussmaul respirations

A client has just undergone bronchoscopy. Which nursing assessment is most important at this time?

Level of Consciousness (LOC)

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 lung disease in the patient or family Occupational and environmental influences Previous history of smoking

The amount of air inspired and expired with each breath is called:

Tidal Volume

Which term refers to the volume of air inhaled or exhaled during each respiratory cycle?

Tidal Volume

Which of the following alveolar cells secrete surfactant?

Type II

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?

Wheezes

A nurse would question the accuracy of a pulse oximetry evaluation in which of the following conditions?

a client experiencing hypothermia

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?

diagnosis of a peripheral vascular disease

What happens to the diaphragm during inspiration?

it contracts and flattens

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?

pleurisy

A 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?

pulmonary embolism

In which position should the client be placed for a thoracentesis?

sitting on the edge of the bed

A student nurse is caring for a client who is severely anemic. The instructor asks the student how anemia affects the transport of oxygen to the cells. What would be the student's best answer?

"The cells are denied adequate oxygen because most of the oxygen in the body is transported by the hemoglobin in red blood cells."

The nurse auscultated a patient's middle lobe of the lungs for abnormal breath sounds. To do this, the nurse placed the stethoscope on the:

anterior surface of the right side of the chest between the fourth and fifth rib

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 nurses' hands move down the patient's thorax

A nurse is preparing a client with a pleural effusion for a thoracentesis. The nurse should:

assist the patient to a sitting position, leaning over the bedside table

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

The nurse inspects the thorax of a patient with advanced emphysema. The nurse expects chest configuration changes consistent with a deformity known as:

barrel chest

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?

bilateral lower lobes

What finding by the nurse may indicate that the client has chronic hypoxia?

clubbing of the fingers

Which of the following clinical manifestations should a nurse monitor for during a pulmonary angiography, which indicates an allergic reaction to the contrast medium?

difficulty in breathing

A nurse is preparing a client for bronchoscopy. Which instruction should the nurse give to the client?

don't eat

A 68-year-old male patient has been admitted to the surgical unit from the PACU after surgical repair of an inguinal hernia. When performing the patient's admission assessment, the nurse notes that the patient has a barrel chest. This assessment finding should suggest to the nurse that the patient may have a history of what health problem?

emphysema

The nurse is caring for a critically ill client in the ICU. The nurse documents the client's respiratory rate as bradypnea. The nurse recognizes that bradypnea is associated with which condition?

increased intracranial pressure

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 be assessed first?

pulse oximetry

The nurse is caring for a client with chronic obstructive pulmonary disease. The client reports that he is having difficulty breathing and is feeling fatigued. The nurse realizes that this client is at high risk for which condition?

respiratory acidosis

The nurse is admitting a client who just had a bronchoscopy. Which assessment should be the nurse's priority?

swallow reflex

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

Which hollow tube transports air from the laryngeal pharynx to the bronchi?

trachea

A client has suspected fluid accumulation in the pleural space of the lungs and is scheduled for a thoracentesis. The nurse will implement which of the following for this procedure? Select all that apply.

Educate the client about the need to cleanse the thoracic area. Apply pressure to the puncture site after the procedure. Complete a respiratory assessment after the procedure.

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?

absence distal pulses

A client has been newly diagnosed with emphysema. The nurse should explain to the client that by definition, ventilation:

is breathing air in and out of the lungs

The nurse answers a client's call light. The client reports 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 the

lungs

Upon palpation of the sinus area, what would the nurse identify as a normal finding?

no sensation during palpation

The student nurse is learning breath sounds while listening to a client in the physician's office. An experienced nurse is assisting and notes air movement over the trachea to the upper lungs. The air movement is noted equally on inspiration as expiration. Which breath sounds would the nurse document?

normal bronchiovescular sounds

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?

orthopnea

Which term will the nurse use to document the inability of a client to breathe easily unless positioned upright?

orthopnea

The nurse auscultates the lung sounds of a client during a routine assessment. The sounds produced are harsh and cracking, sounding like two pieces of leather being rubbed together. The nurse would be correct in documenting this finding as

pleural friction rub

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 can be heard during inspiration and expiration

Millions of alveoli form most of the pulmonary mass. The squamous epithelial cells lining each alveolus consist of different types of cells. Which type of alveolar cells produce surfactant?

type II cells

A nurse assesses a client's respiratory status. Which observation indicates that the client is having difficulty breathing?

use of accessory muscles

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 exceeds perfusion

What is the difference between respiration and ventilation?

ventilation is the movement of air in and out of the respiratory tract