Chapter 23: Assessment of Respiratory Function

4. The nurse is conducting a respiratory assessment for a patient who is diagnosed with asthma. Which assessment finding does the nurse monitor for with this diagnosis? 1. Hemoptysis 2. Dry cough 3. Productive cough 4. Coarse crackles

2 A dry cough may be from asthma, a viral infection, or seasonal allergies.

18. The nurse correlated respiratory acidosis in a patient with which arterial blood gas result? 1. pH 7.50 2. PaCO2 50 mm Hg 3. PaO2 80 mm Hg 4. HCO3- 20 mEq/L

2 PaCO2 greater than 45 mm Hg and pH less than 7.35 correlate with respiratory acidosis.

5. The nurse is assessing a patient who is diagnosed with tuberculosis. Which assessment finding supports this diagnosis? 1. Wheezing 2. Hemoptysis 3. Pleural friction rub 4. Slightly whitish sputum

2 Tuberculosis is characterized by hemoptysis, which is the term for coughing up of blood or blood-tinged sputum from the respiratory tract.

16. A patient is admitted for evaluation of complaints of difficulty breathing and is scheduled for a sputum study to assist in providing data for which diagnosis? 1. Asthma 2. Lung cancer 3. Bacterial lung infection 4. Chronic obstructive pulmonary disease

3 A sputum study is often used to diagnose bacterial lung infections via a culture and sensitivity analysis.

20. A patient is scheduled for pulmonary function testing. Which nursing action is most appropriate for the patient? 1. Assessing for respiratory distress 2. Scheduling the test after a meal 3. Providing rest before the procedure 4. Administering an inhaled bronchodilator 6 hours before procedure

1 A nursing action that is appropriate when providing care to a patient who is having pulmonary function tests is to assess the patient for respiratory distress.

7. The nurse educator is teaching a student nurse how to auscultate the lungs. Which action by the student nurse indicates the need for further education? 1. Listening to sound over the bony structures 2. Asking the patient to sit in an upright position 3. Instructing the patient to breathe slowly through mouth 4. Beginning auscultation from lung apices and moving toward intercostal spaces

1 Auscultation is performed to identify fluid, mucus, or obstruction in the respiratory system. The nurse should avoid auscultating sound over bony structures because it interferes with the sound quality. level.

19. In reviewing capnography data, the nurse monitors for increased end-tidal volume CO2 in patients with which disorder? 1. Sepsis 2. Hypothermia 3. Esophageal intubation 4. Cardiac arrest

1 Increases in end-tidal CO2 levels may be from an increase in cellular metabolism, resulting in an increase in CO2 production or hyperventilation that causes an increase in the excretion of CO2 from the lungs. Disease processes that result in increased CO2 levels are hyperthermia, trauma, burns, or sepsis.

6. The nurse uses palpation during respiratory assessment to determine which clinical finding? 1. Tracheal position 2. Bronchovesicular sounds 3. Lung density 4. Adventitious sounds

1 Palpation is used to determine tracheal position.

24. The nurse conducts a respiratory assessment for an adult patient who presents with a productive cough. Which additional data require the nurse to request the healthcare provider to test the patient for tuberculosis? Select all that apply. 1. A low-grade fever 2. Reports of night sweats 3. Reports of coughing up blood 4. Reports of heart palpitations 5. Weight loss from previous visit

24. ANS: 1, 2, 3, 5 Chapter number and title: 23, Assessment of Respiratory Function Chapter learning objective: 3. Describing the procedure for completing a history and physical assessment of respiratory function Chapter page reference: 446 Heading: Cough/Safety Alert Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Infection Difficulty: Difficult Feedback 1 This is correct. The patient who presents with a productive cough in addition to a low-grade fever should be tested for tuberculosis. 2 This is correct. The patient who presents with a productive cough in addition to reports of night sweats should be tested for tuberculosis. 3 This is correct. The patient who presents with a productive cough in addition to hemoptysis (coughing up blood) should be tested for tuberculosis. 4 This is incorrect. Heart palpations with a productive cough is not an indicator of tuberculosis. Although the report of palpitations should be reported to the healthcare provider, this does not support a need to test the patient for tuberculosis. 5 This is correct. The patient who presents with a productive cough in addition to reported or actual weight loss should be tested for tuberculosis.

25. The nurse assesses for coarse crackles (coarse rales) in patients admitted with which respiratory disorders? Select all that apply. 1. Asthma 2. Bronchitis 3. Chronic obstructive pulmonary disease (COPD) 4. Pneumonia 5. Pulmonary edema

25. ANS: 3, 4, 5 Chapter number and title: 23, Assessment of Respiratory Function Chapter learning objective: 3. Describing the procedure for completing a history and physical assessment of respiratory function Chapter page reference: 448-450 Heading: Assessment/Auscultation/Table 23.4 - Abnormal or Adventitious Lung Sounds Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Comprehension [Understanding] Concept: Assessment Difficulty: Moderate Feedback 1 This is incorrect. Patients with asthma typically develop wheezing that is described as a squeaky musical instrument caused by bronchoconstriction and inflammation. 2 This is incorrect. Patients with bronchitis may have fine rhonchi (fine rales), described as the sound of rubbing hair follicles together caused by inflation of previously deflated lung tissue, or rhonchi, described as snoring sounds caused by obstruction in the airways. 3 This is correct. Coarse crackles (coarse rales), described as a popping/coarse sound caused by fluid or secretions in lower airways, may be observed in patients with COPD, sputum in the airways, pneumonia, pulmonary edema, and congestive heart failure. 4 This is correct. Coarse crackles (coarse rales), described as a popping/coarse sound caused by fluid or secretions in lower airways, may be observed in patients with COPD, sputum in the airways, pneumonia, pulmonary edema, and congestive heart failure. 5 This is correct. Coarse crackles (coarse rales), described as a popping/coarse sound caused by fluid or secretions in lower airways, may be observed in patients with COPD, sputum in the airways, pneumonia, pulmonary edema, and congestive heart failure.

26. The nurse assesses for fine crackles (fine rales) in patients admitted with which respiratory disorders? Select all that apply. 1. Pneumonia 2. Pulmonary edema 3. Fibrosis 4. Chronic obstructive pulmonary disease (COPD) 5. Asthma

26. ANS: 1, 3, 4 Chapter number and title: 23, Assessment of Respiratory Function Chapter learning objective: 3. Describing the procedure for completing a history and physical assessment of respiratory function Chapter page reference: 448-450 Heading: Assessment/Auscultation/Table 23.4 - Abnormal or Adventitious Lung Sounds Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Comprehension [Understanding] Concept: Assessment Difficulty: Moderate Feedback 1 This is correct. Patients with bronchitis, COPD, fibrosis, and pneumonia may have fine crackles (fine rales) that are described as the sound of rubbing hair follicles together caused by inflation of previously deflated lung tissue. 2 This is incorrect. Patients with pulmonary edema usually manifest with coarse crackles as a result of fluid in the lower airways. 3 This is correct. Patients with bronchitis, COPD, fibrosis, and pneumonia may have fine crackles (fine rales) that are described as the sound of rubbing hair follicles together caused by inflation of previously deflated lung tissue. 4 This is correct. Patients with bronchitis, COPD, fibrosis, and pneumonia may have fine crackles (fine rales) that are described as the sound of rubbing hair follicles together caused by inflation of previously deflated lung tissue. 5 This is incorrect. Patients with asthma typically develop wheezing that is described as a squeaky musical instrument caused by bronchoconstriction and inflammation.

27. The nurse assesses for rhonchi in patients admitted with which respiratory disorders? Select all that apply. 1. Asthma 2. Chronic obstructive pulmonary disease (COPD) 3. Foreign body in airway 4. Lung cancer 5. Pneumonia

27. ANS: 3, 4, 5 Chapter number and title: 23, Assessment of Respiratory Function Chapter learning objective: 3. Describing the procedure for completing a history and physical assessment of respiratory function Chapter page reference: 448-450 Heading: Assessment/Auscultation/Table 23.4 - Abnormal or Adventitious Lung Sounds Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Comprehension [Understanding] Concept: Assessment Difficulty: Moderate Feedback 1 This is incorrect. Patients with asthma typically develop wheezing that is described as a squeaky musical instrument caused by bronchoconstriction and inflammation. 2 This is incorrect. Patients with COPD typically have fine or coarse crackles on auscultation. 3 This is correct. Rhonchi are auscultated in patients with bronchitis, foreign body obstruction, masses or malignancies in the lungs, and pneumonia. 4 This is correct. Rhonchi are auscultated in patients with bronchitis, foreign body obstruction, masses or malignancies in the lungs, and pneumonia. 5 This is correct. Rhonchi are auscultated in patients with bronchitis, foreign body obstruction, masses or malignancies in the lungs, and pneumonia.

28. The nurse assesses for stridor in patients admitted with which respiratory disorders? Select all that apply. 1. Allergic reactions 2. Chronic obstructive pulmonary disease (COPD) 3. Epiglottis 4. Laryngitis 5. Pleurisy

28. ANS: 1, 3, 4 Chapter number and title: 23, Assessment of Respiratory Function Chapter learning objective: 3. Describing the procedure for completing a history and physical assessment of respiratory function Chapter page reference: 448-450 Heading: Assessment/Auscultation/Table 23.4 - Abnormal or Adventitious Lung Sounds Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Comprehension [Understanding] Concept: Assessment Difficulty: Moderate Feedback 1 This is correct. Stridor, described as a high-pitched sound during inspiration caused by airway obstruction of the throat or upper airway or spasm of the airway, may be auscultated in patients with allergic reactions, epiglottis, and laryngitis. 2 This is incorrect. Patients with COPD typically have fine or coarse crackles on auscultation. 3 This is correct. Stridor, described as a high-pitched sound during inspiration caused by airway obstruction of the throat or upper airway or spasm of the airway, may be auscultated in patients with allergic reactions, epiglottis, and laryngitis. 4 This is correct. Stridor, described as a high-pitched sound during inspiration caused by airway obstruction of the throat or upper airway or spasm of the airway, may be auscultated in patients with allergic reactions, epiglottis, and laryngitis. 5 This is incorrect. Pleural friction rubs are auscultated in patients with pleurisy. These sounds, described as grating or squeaking, are caused by inflammation in the pleural space.

29. Which finding in a patient with dyspnea requires an immediate intervention by the nurse? Select all that apply. 1. Accessory muscle use 2. Cyanosis 3. Hyperventilation 4. Tachypnea 5. Vesicular breath sounds

29. ANS: 1, 2, 4 Chapter number and title: 23, Assessment of Respiratory Function Chapter learning objective: 4. Correlating relevant diagnostic examinations to respiratory function Chapter page reference: 448 Heading: Auscultation/Safety Alert: Dyspnea Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Analysis [Analyzing] Concept: Oxygenation Difficulty: Moderate Feedback 1 This is correct. Patients who are reporting dyspnea demonstrate accessory muscle use, adventitious breath sounds, cyanosis, retractions, and tachypnea and should be referred for immediate medical intervention. 2 This is correct. Patients who are reporting dyspnea demonstrate accessory muscle use, adventitious breath sounds, cyanosis, retractions, and tachypnea and should be referred for immediate medical intervention. 3 This is incorrect. Patients with dyspnea who have worsening of respiratory status will manifest tachypnea, not hyperventilation. 4 This is correct. Patients who are reporting dyspnea demonstrate accessory muscle use, adventitious breath sounds, cyanosis, retractions, and tachypnea and should be referred for immediate medical intervention. 5 This is incorrect. Vesicular are normal breath sounds.

22. The nurse prepares the patient for which diagnostic procedure that is used to remove pleural fluid for analysis? 1. Lung biopsy 2. Bronchoscopy 3. Thoracentesis 4. Sputum studies

3 A thoracentesis is a diagnostic procedure used to remove pleural fluid for analysis or to instill medication.

8. The nurse uses which the term to describe abnormal breath sounds? 1. Vesicular 2. Bronchial 3. Adventitious 4. Bronchovesicular

3 Adventitious is the term used to describe abnormal breath sounds such as crackles, rhonchi, wheezes, and a pleural friction rub.

12. Where does the nurse auscultate bronchial vesicular sounds? 1. Neck 2. Trachea 3. First to second intercoastal spaces 4. Peripheral lung fields

3 Bronchovesicular sounds, described as tubular with moderate intensity are auscultated from the first to the second intercoastal spaces.

13. The nurse is assessing a patient who is admitted with pulmonary edema and presents with a persistent cough. Which assessment finding is consistent with this diagnosis? 1. Foul-smelling sputum 2. Wheezing 3. Coarse crackles 4. Stridor

3 Coarse rhonchi (rales) are caused by secretions in the lower airway and often observed in patients with pulmonary edema, congestive heart failure, pneumonia, and COPD.

10. When percussing the patient's lung fields, the nurse notes a long, hollow, loud pitched sound over the chest. The nurse uses which term to describe this in the health record? 1. Dull 2. Tympany 3. Resonance 4. Hyperresonance

3 Low-pitched sounds heard over normal lungs during percussion indicate resonance.

1. The nurse recognizes that which process occurs as oxygen and carbon dioxide are exchanged at the level of the alveoli. 1. Diffusion 2. Perfusion 3. Respiration 4. Ventilation

3 The process of respiration occurs as oxygen and carbon dioxide are exchanged at the level of the alveoli.

30. The nurse correlates which of the following assessment findings to age-related changes of the respiratory system? Select all that apply. 1. Decreased airway reactivity 2. Decreased chest compliance 3. Decreased intercostal strength 4. Increased risk for hypocapnia 5. Increased neutrophils in respiratory tissue

30. ANS: 2, 3, 5 Chapter number and title: 23, Assessment of Respiratory Function Chapter learning objective: 6. Discussing changes in respiratory function associated with aging Chapter page reference: 456-457 Heading: Age-Related Changes of the Respiratory System/Table 23.8 - Age-Related Changes of the Respiratory System Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Comprehension [Understanding] Concept: Assessment Difficulty: Moderate Feedback 1 This is incorrect. The airways of older adults are more reactive than those of younger adults. 2 This is correct. Kyphosis and osteoporosis of the thoracic vertebrae cause a decrease in chest wall compliance. 3 This is correct. The decrease in function and strength of the intercostals and diaphragm increases inspiratory effort to maintain adequate ventilation. 4 This is incorrect. Older adults have an increased potential for hypercapnia and hypoxia related to age-related changes that depress the cough reflex and ventilatory response. 5 This is correct. There is an increase in neutrophils, along with a decrease in macrophages that create chronic inflammation of the lung tissue in older adults.

21. The nurse is providing care to a patient who will need a bronchoscopy. Which patient statement indicates that pre-procedure teaching was effective? 1. "I will be awake and fully conscious during the procedure." 2. "I will require mechanical ventilation after the procedure." 3. "I will need to have my prothrombin time drawn after the test." 4. "I will abstain from eating or drinking for 8 hours before the procedure."

4 A bronchoscopy is the insertion of a tube in the airways to view airway structure and obtain tissue sample for biopsy or culture. The patient will need to be NPO for 8 hours before the procedure to decrease the risk for aspiration.

11. The nurse correlates which percussion sound to the patient diagnosed with emphysema? 1. Flat 2. Dull 3. Tympany 4. Hyperresonance

4 A hyperresonance percussion sound is anticipated when assessing the patient who is diagnosed with emphysema, chronic asthma, or a pneumothorax.

15. Before an arterial blood gas is collected from the radial artery, an Allen's test is preformed to access the patency of which artery? 1. Brachial 2. Medial 3. Radial 4. Ulnar

4 If the nurse elects to use the radial artery, assessment of the ulnar circulation needs to be evaluated using Allen's test to ensure adequate collateral circulation.

23. The nursing diagnosis "Ineffective Breathing Pattern related to decreased chest wall compliance" is most relevant to the older adult patient with which condition? 1. Decreased diaphragmatic strength 2. Delays in gas exchange 3. Depressed cough reflex 4. Kyphosis

4 Kyphosis and osteoporosis of the thoracic vertebrae cause a decrease in chest wall compliance.

17. How does the nurse interpret these arterial blood gas results? pH 7.48 PaCO2 30 mm Hg HCO3 24 mEq/L 1. Metabolic acidosis 2. Respiratory acidosis 3. Metabolic alkalosis 4. Respiratory alkalosis

4 PaCO2 less than 35 mm Hg and pH greater than 7.45 correlate with respiratory alkalosis.

3. In providing health education to a group of middle school students, how does the nurse describe the function of the epiglottis? 1. Aids in the sensation of smell 2. Conducts gases to the alveoli 3. Filters small particles before air enters the lungs 4. Prevents the entry of solids and liquids into the lungs

4 The epiglottis is a small flap located behind the tongue that closes over the larynx during swallowing. The function of the epiglottis is to prevent solids and liquids from entering the lungs.

9. Which percussion sound does the nurse expect when conducting percussion between the ribs during a respiratory assessment? 1. Flat 2. Dull 3. Tympany 4. Resonance

4 The nurse expects a resonance sound when percussing between the rib during a respiratory assessment.

2. Which structure of the respiratory system is responsible for filtering, warming, and humidifying inhaled air? 1. Alveoli 2. Pharynx 3. Sinuses 4. Turbinates

4 Turbinates filter the air, and any foreign matter is filtered out through the cilia. In addition to filtering the air entering the nostril, turbinates are responsible for humidifying and warming the air.

14. While auscultating a patient's chest, the nurse notes wheezing, and correlates this finding with which disorder? 1. Bronchitis 2. Pleural effusion 3. Pulmonary edema 4. Chronic obstructive pulmonary disease

4 Wheezes are continuous high-pitched squeaking or rapid sounds caused by the rapid vibration of the bronchial walls, which is caused by a blockage in airways that often occurs with chronic obstructive pulmonary disease.