Chapter 26: Nursing assessment, Respiratory System
NCLEX pre-test question: The nurse is interpreting a tuberculin skin test (TST) for a 58-year-old female patient with end-stage kidney disease secondary to diabetes mellitus. Which finding would indicate a positive reaction?
11-mm area of induration at the TST injection site Rationale: An area of induration ≥ 10 mm would be a positive reaction in a person with end-stage kidney disease. Reddened, flat areas do not indicate a positive reaction. A wheal appears when the TST is administered that indicates correct administration of the intradermal antigen. Presence of acid-fast bacilli in the sputum indicates active tuberculosis.
Normal capnography range:
37-50 mm Hg
NCLEX practice question: The nurse is caring for a patient with chronic obstructive pulmonary disorder (COPD) and pneumonia who has an order for arterial blood gases to be drawn. What is the minimum length of time the nurse should plan to hold pressure on the puncture site?
5 minutes Rationale: After obtaining blood for an arterial blood gas measurement, the nurse should hold pressure on the puncture site for 5 minutes by the clock to be sure that bleeding has stopped. An artery is an elastic vessel under much higher pressure than veins, and significant blood loss or hematoma formation could occur if the time is insufficient.
NCLEX pre-test questions: Which patient is exhibiting an early clinical manifestation of hypoxemia?
A 72-year-old patient who has four new premature ventricular contractions per minute Rationale: Early clinical manifestations of hypoxemia include dysrhythmias (e.g., premature ventricular contractions), unexplained decreased level of consciousness (e.g., disorientation), dyspnea on exertion, and unexplained decreased urine output
Inspection: ↑AP diameter
AP chest diameter equal to lateral; slope of ribs more horizontal (90 degrees) to spine. possible etiology: COPD, asthma, cystic fibrosis, lung hyperinflation, advanced age.
Inspection: Abdominal paradox
Abdominal paradox Inward (rather than normal outward) movement of abdomen during inspiration. possible etiology: Inefficient and ineffective breathing pattern. Nonspecific indicator of severe respiratory distress.
Cheyne-Stokes respirations
Abnormal breathing patter characterized by alternating periods of apnea and deep, rapid breathing
Kussmaul respirations
Abnormal breathing pattern characterized by rapid, deep breathing
Biot's respirations
Abnormal breathing pattern with apnea every four to five cycles
NCLEX bridge question: When teaching a patient about the most important respiratory defense mechanism distal to the respiratory bronchioles, which topic would the nurse discuss?
Alveolar macrophages Rationale: Respiratory defense mechanisms are efficient in protecting the lungs from inhaled particles, microorganisms, and toxic gases. Because ciliated cells are not found below the level of the respiratory bronchioles, the primary defense mechanism at the alveolar level is alveolar macrophages.
NCLEX practice question: The patient is hospitalized with pneumonia. Which diagnostic test should be used to measure the efficiency of gas transfer in the lung and tissue oxygenation?
Arterial blood gas (ABG) Rationale: Arterial blood gases are used to assess the efficiency of gas transfer in the lung and tissue oxygenation as is pulse oximetry. Thoracentesis is used to obtain specimens for diagnostic evaluation, remove pleural fluid, or instill medication into the pleural space. Bronchoscopy is used for diagnostic purposes, to obtain biopsy specimens, and to assess changes resulting from treatment. Pulmonary function tests measure lung volumes and airflow to diagnose pulmonary disease, monitor disease progression, evaluate disability, and evaluate response to bronchodilators.
NCLEX bridge question: The nurse can best determine adequate arterial oxygenation of the blood by assessing...
Arterial oxygen tension Rationale: The ability of the lungs to oxygenate arterial blood adequately is determined by examination of the partial pressure of oxygen in arterial blood (PaO2) and arterial oxygen saturation (SaO2).
NCLEX practice question: The patient had abdominal surgery yesterday. Today the lung sounds in the lower lobes have decreased. The nurse knows this could be due to what occurring?
Atelectasis Rationale: Postoperatively there is an increased risk for atelectasis from anesthesia as well as restricted breathing from pain. Without deep breathing to stretch the alveoli, surfactant secretion to hold the alveoli open is not promoted. Pneumonia will occur later after surgery. Pleural effusion occurs because of blockage of lymphatic drainage or an imbalance between intravascular and oncotic fluid pressures, which is not expected in this case.
NCLEX pre-test questions: The nurse is obtaining a focused respiratory assessment of a 44-year-old female patient who is in severe respiratory distress 2 days after abdominal surgery. What is most important for the nurse to assess?
Auscultation of bilateral breath sounds Rationale: Important assessments obtained during a focused respiratory assessment include auscultation of lung (breath) sounds. Assessment of tactile fremitus has limited value in acute respiratory distress. It is not necessary to assess for both anterior and posterior chest expansion. Percussion of the chest wall is not essential in a focused respiratory assessment.
NCLEX pre-test question: A frail 82-year-old female patient develops sudden shortness of breath while sitting in a chair. What location on the chest should the nurse begin auscultation of the lung fields?
Bases of posterior chest area Rationale: Baseline data with the most information is best obtained by auscultation of the posterior chest, especially in female patients because of breast tissue interfering with the assessment or if the patient may tire easily (e.g., shortness of breath, dyspnea, weakness, fatigue). Usually auscultation proceeds from the lung apices to the bases unless it is possible the patient will tire easily. In this case the nurse should start at the bases.
Inspection: Cyanosis
Bluish color of skin best seen in lips and on the palpebral conjunctiva (inside the lower eyelid). possible etiology: Reflects 5-6 g of hemoglobin not bound with O2. ↓O2 transfer in lungs, ↓cardiac output. Nonspecific, unreliable indicator.
NCLEX practice question: The nurse, when auscultating the lower lungs of the patient, hears these breath sounds. How should the nurse document these sounds?
Coarse crackles Rationale: Coarse crackles are a series of long-duration, discontinuous, low-pitched sounds caused by air passing through an airway intermittently occluded by mucus, an unstable bronchial wall, or a fold of mucosa. Coarse crackles are evident on inspiration and at times expiration. Stridor is a continuous crowing sound of constant pitch from partial obstruction of larynx or trachea. Rhonchi are a continuous rumbling, snoring, or rattling sound from obstruction of large airways with secretions. Bronchovesicular sounds are normal sounds heard anteriorly over the mainstem bronchi on either side of the sternum and posteriorly between the scapulae with a medium pitch and intensity.
wheezes
Continuous high-pitched squeaking or musical sound caused by rapid vibration of bronchial walls. First evident on expiration but possibly evident on inspiration as obstruction of airway increases. Possibly audible without stethoscope. etiology: Bronchospasm (caused by asthma), airway obstruction (caused by foreign body, tumor), COPD
stridor
Continuous musical or crowing sound of constant pitch. Result of partial obstruction of larynx or trachea. etiology: Croup, epiglottitis, vocal cord edema after extubation, foreign body.
rhonchi
Continuous rumbling, snoring, or rattling sounds from obstruction of large airways with secretions. Most prominent on expiration. Change often evident after coughing or suctioning. etiology: COPD, cystic fibrosis, pneumonia, bronchiectasis.
NCLEX practice question: The patient is calling the clinic with a cough. What assessment should be made first before the nurse advises the patient?
Cough sound, sputum production, pattern Rationale: The sound of the cough, sputum production and description, as well as pattern of the cough's occurrence (including acute or chronic) and what its occurrence is related to are the first assessments to be made to determine the severity. Frequency of the cough will not provide a lot of information. Family history can help to determine a genetic cause of the cough. Hematemesis is vomiting blood and not as important as hemoptysis. Smoking is an important risk factor for COPD and lung cancer and may cause a cough. Medications may or may not contribute to a cough as does residence location. Weight loss, activity intolerance, and orthopnea may be related to respiratory or cardiac problems, but are not as important when dealing with a cough.
pericardial friction rub
Creaking or grating sound from roughened, inflamed pleural surfaces rubbing together. Evident during inspiration, expiration, or both and no change with coughing. Usually uncomfortable, especially on deep inspiration. etiology: Pleurisy, pneumonia, pulmonary infarct.
NCLEX bridge question: A patient with a respiratory condition asks "How does air get into my lungs?" The nurse bases her answer on her knowledge that air moves into the lungs because of...
Decrease in intrathoracic pressure relative to pressure at the airway Rationale: During inspiration, the diaphragm contracts, increasing intrathoracic volume and pushing the abdominal contents downward. At the same time, the external intercostal muscles and scalene muscles contract, increasing the lateral and anteroposterior dimension of the chest. This causes the size of the thoracic cavity to increase and intrathoracic pressure to decrease, which enables air to enter the lungs.
NCLEX practice question: After swallowing, a 73-year-old patient is coughing and has a wet voice. What changes of aging could be contributing to this abnormality?
Decreased respiratory defense mechanisms Rationale: These manifestations are associated with aspiration, which more easily occur in the right lung as the right mainstem bronchus is shorter, wider, and straighter than the left mainstem bronchus. Aspiration occurs more easily in the older patient related to decreased respiratory defense mechanisms (e.g., decreases in immunity, ciliary function, cough force, sensation in pharynx). Changes of aging include a decreased response to hypercapnia, decreased number of functional alveoli, and increased calcification of costal cartilage, but these do not increase the risk of aspiration.
Inspection: pursed-lip breathing
Exhalation through mouth with lips pursed together to slow exhalation. possible etiology: COPD, asthma. Suggests ↑breathlessness. Strategy taught to slow expiration, ↓dyspnea.
NCLEX pre-test questions: A 67-year-old male patient had a right total knee replacement 2 days ago. Upon auscultation of the patient's posterior chest, the nurse detects discontinuous, high-pitched breath sounds just before the end of inspiration in the lower portion of both lungs. Which statement most appropriately reflects how the nurse should document the breath sounds?
Fine crackles posterior right and left lower lung fields Rationale: Fine crackles are described as a series of short-duration, discontinuous, high-pitched sounds heard just before the end of inspiration
NCLEX practice question: What should the nurse inspect when assessing a patient with shortness of breath for evidence of long-standing hypoxemia?
Fingernails and their base Rationale: Clubbing, a sign of long-standing hypoxemia, is evidenced by an increase in the angle between the base of the nail and the fingernail to 180 degrees or more, usually accompanied by an increase in the depth, bulk, and sponginess of the end of the finger.
NCLEX practice question: When assessing a patient's sleep-rest pattern related to respiratory health, what three things should the nurse ask the patient about?
Have trouble falling asleep? Awaken abruptly during the night? Need to sleep with the head elevated? Rationale: The patient with sleep apnea may have insomnia and/or abrupt awakenings. Patients with cardiovascular disease (e.g., heart failure that may affect respiratory health) may need to sleep with the head elevated on several pillows (orthopnea). Sleeping more than 8 hours per night or needing to urinate during the night is not indicative of impaired respiratory health.
Palpation: altered tactile fremitus
Increase or decrease in vibrations. possible etiology: ↑In pneumonia, pulmonary edema. ↓In pleural effusion, lung hyperinflation. Absent in pneumothorax, atelectasis.
Inspection: tripod position, inability to lie flat
Learning forward with arms and elbows supported on overbed table. possible etiology: COPD, asthma in exacerbation, pulmonary edema. Indicates moderate to severe respiratory distress.
Palpation: tracheal deviation
Leftward or rightward movement of trachea from normal midline position. possible etiology: Nonspecific indicator of change in position of mediastinal structures. Medical emergency if caused by tension pneumothorax. Trachea deviates to the side opposite the collapsed lung.
Percussion: Hyperresonance
Loud, lower-pitched sound over areas that normally produce a resonant sound. possible etiology: Lung hyperinflation (COPD), lung collapse (pneumothorax), air trapping (asthma).
Percussion: Dullness
Medium-pitched sound over areas that normally produce a resonant sound. possible etiology: ↑Density (pneumonia, large atelectasis),↑fluid in pleural space (pleural effusion).
NCLEX practice question: A patient with recurrent shortness of breath has just had a bronchoscopy. What is a priority nursing action immediately following the procedure?
Monitor the patient for laryngeal edema Rationale: Priorities for assessment are the patient's airway and breathing, both of which may be compromised after bronchoscopy by laryngeal edema. These assessment parameters supersede the importance of loss of consciousness (LOC), pain, heart rate, and blood pressure, although the nurse should also be assessing these.
NCLEX practice question: The patient with Parkinson's disease has a pulse oximetry reading of 72%, but he is not displaying any other signs of decreased oxygenation. What is most likely contributing to his low SpO2 level?
Motion Rationale: Motion is the most likely cause of the low SpO2 for this patient with Parkinson's disease. Anemia, dark skin color, and thick acrylic nails as well as low perfusion, bright fluorescent lights, and intravascular dyes may also cause an inaccurate pulse oximetry result. There is no mention of these or reason to suspect these in this question.
Inspection: Accessory muscle use; intercostal retractions
Neck and shoulder muscles used to assist breathing; muscles between ribs pull in during inspiration. possible etiology: COPD, asthma in exacerbation, secretion retention. Indicates severe respiratory distress, hypoxemia.
absent breath sounds
No sound evident over entire lung or area of lung. etiology: Pleural effusion, mainstem bronchi obstruction, large atelectasis, pneumonectomy, lobectomy.
NCLEX practice question: After assisting at the bedside with a thoracentesis, the nurse should continue to assess the patient for signs and symptoms of what?
Pneumothorax Rationale: Because thoracentesis involves the introduction of a catheter into the pleural space, there is a risk of pneumothorax. Thoracentesis does not carry a significant potential for causing bronchospasm, pulmonary edema, or respiratory acidosis.
NCLEX practice question: A patient with a recent history of a dry cough has had a chest x-ray that revealed the presence of nodules. In an effort to determine whether the nodules are malignant or benign, what is the primary care provider likely to order?
Positron emission tomography (PET) Rationale: PET is used to distinguish benign and malignant pulmonary nodules. Because malignant lung cells have an increased uptake of glucose, the PET scan (which uses an IV radioactive glucose preparation) can demonstrate increased uptake of glucose in malignant lung cells. This differentiation cannot be made using CT, a pulmonary angiogram, or thoracentesis.
NCLEX practice question: When the patient is experiencing metabolic acidosis secondary to type 1 diabetes mellitus, what physiologic response should the nurse expect to assess in the patient?
Rapid respiratory rate Rationale: When a patient with type 1 diabetes has hyperglycemia and ketonemia causing metabolic acidosis, the physiologic response is to increase the respiratory rate and tidal volume to blow off the excess CO2. Vomiting and increased urination may occur with hyperglycemia, but not as physiologic responses to metabolic acidosis. The heart rate will increase.
Inspection: tachypnea
Rate >20 breaths/min; >25 breaths/min in older adults. possible etiology: Fever, anxiety, hypoxemia, restrictive lung disease. Magnitude of ↑above normal rate reflects increased work of breathing.
Inspection: Kussmaul respirations
Regular, rapid, and deep respirations. possible etiology: Metabolic acidosis. Increases CO2 excretion.
NCLEX practice question: The patient's arterial blood gas results show the PaO2 at 65 mmHg and the SaO2 at 80%. What early manifestations should the nurse expect to observe in this patient?
Restlessness, tachypnea, tachycardia, and diaphoresis Rationale: With inadequate oxygenation, early manifestations include restlessness, tachypnea, tachycardia, and diaphoresis, decreased urinary output, and unexplained fatigue. The unexplained confusion, dyspnea at rest, hypotension, and diaphoresis; combativeness, retractions with breathing, cyanosis, and decreased urinary output; coma, accessory muscle use, cool and clammy skin, and unexplained fatigue occur as later manifestations of inadequate oxygenation.
coarse crackles
Series of long-duration, discontinuous, low-pitched sounds caused by air passing through airway intermittently occluded by mucus, unstable bronchial wall, or fold of mucosa. Evident on inspiration and, at times, expiration. Similar sound to blowing through straw under water. etiology: Heart failure, pulmonary edema, pneumonia with severe congestion, COPD.
fine crackles
Series of short-duration, discontinuous, high-pitched sounds heard just before the end of inspiration. Result of rapid equalization of gas pressure when collapsed alveoli or terminal bronchioles suddenly snap open. Similar sound to that made by rolling hair between fingers just behind ear. etiology: Idiopathic pulmonary fibrosis, interstitial edema (early pulmonary edema), alveolar filling (pneumonia), loss of lung volume (atelectasis), early phase of heart failure.
Bronchophony, whispered pectoriloquy
Spoken or whispered syllable more distinct than normal on auscultation. etiology: pneumonia
egophony
Spoken"E"similar to"A"on auscultation because of altered transmission of voice sounds. etiology: pneumonia, pleural effusion
NCLEX bridge question: To promote the release of surfactant, the nurse encourages the patient to...
Take deep breaths Rationale: Surfactant is a lipoprotein that lowers the surface tension in the alveoli. It reduces the amount of pressure needed to inflate the alveoli and decreases the tendency of the alveoli to collapse. Deep breaths stretch the alveoli and promote surfactant secretion.
NCLEX bridge question: The nurse is preparing the patient for a diagnostic procedure to remove pleural fluid for analysis. The nurse would prepare the patient for which test?
Thoracentesis Rationale: Thoracentesis is the insertion of a large-bore needle through the chest wall into the pleural space to obtain specimens for diagnostic evaluation, remove pleural fluid, or instill medication into the pleural space.
NCLEX practice question: During the assessment in the ED, the nurse is palpating the patient's chest. Which finding is a medical emergency?
Trachea moved to the left Rationale: Tracheal deviation is a medical emergency when it is caused by a tension pneumothorax. Tactile fremitus increases with pneumonia or pulmonary edema and decreases in pleural effusion or lung hyperinflation. Diminished chest movement occurs with barrel chest, restrictive disease, and neuromuscular disease.
NCLEX practice question: In assessment of the patient with acute respiratory distress, what are two things the nurse should expect to observe?
Tripod position Accessory muscle use Rationale: Tripod position and accessory muscle use indicate moderate to severe respiratory distress. Cyanosis may be related to anemia, decreased oxygen transfer in the lungs, or decreased cardiac output. Therefore it is a nonspecific and unreliable indicator of only respiratory distress. Kussmaul respirations occur when the patient is in metabolic acidosis to increase CO2 excretion. Increased AP diameter occurs with lung hyperinflation from COPD, cystic fibrosis, or with advanced age.
Palpation: altered chest movement
Unequal or equal but diminished movement of two sides of chest with inspiration. possible etiology: Unequal movement caused by atelectasis, pneumothorax, pleural effusion, splinting. Equal but diminished movement caused by barrel chest, restrictive disease, neuromuscular disease.
Inspection: splinting
Voluntary↓in tidal volume to↓pain on chest expansion. possible etiology: Thoracic or abdominal incision, chest trauma, pleurisy.
NCLEX bridge question: A student nurse asks the RN what can be measured by arterial blood gases (ABGs). The RN tells the student that the ABGs can measure...
acid-base balance oxygenation status. acidity of the blood. bicarbonate (HCO3-) in arterial blood. Rationale: Arterial blood gases (ABGs) are measured to determine oxygenation status and acid-base balance. ABG analysis includes measurement of the PaO2, the partial pressure of carbon dioxide in arterial blood (PaCO2), acidity (pH), and bicarbonate (HCO3-) in arterial blood.
NCLEX bridge question: To detect early signs or symptoms of inadequate oxygenation, the nurse would examine the patient for...
apprehension and restlessness Rationale: Early symptoms of inadequate oxygenation include unexplained restlessness, apprehension, and irritability.
NCLEX bridge question: When auscultating the chest of an older patient in respiratory distress, it is best to...
begin listening at the lung bases Rationale: Normally, auscultation should proceed from the lung apices to the bases, so that opposite areas of the chest are compared. If the patient is likely to tire easily or has respiratory distress, start at the bases.
NCLEX bridge question: Which assessment finding of the respiratory system does the nurse interpret as abnormal?
bronchial breath sounds in the lower lung fields Rationale: Bronchial or bronchovesicular sounds heard in the peripheral lung fields are abnormal breath sounds.
NCLEX bridge question: When assessing activity-exercise patterns related to respiratory health, the nurse inquires about ...
dyspnea during rest or exercise Rationale: In this functional health pattern, determine whether the patient's activity is limited by dyspnea at rest or during exercise.
Blood study that is increased in chronic hypoxemia
hematocrit
NCLEX bridge question: During the respiratory assessment of the older adult, the nurse would expect to find what two things?
increased residual volume increased anteroposterior (AP) chest diameter Rationale: The anterior-posterior diameter of the thoracic cage and the residual volume increase in older adults. An older adult has a less forceful cough. The costal cartilages calcify with aging and interfere with chest expansion. Small airways in the lung bases close earlier during expiration. As a consequence, more inspired air is distributed to the lung apices, ventilation is less well matched to perfusion, and the PaO2 is lowered
chest exam findings: COPD
inspection: Barrel chest, cyanosis, tripod position, use of accessory muscles palpation: decreased movement percussion: hyperresonant or dull if consolidation auscultation: crackles, rhonchi, wheezes, distant breath sounds
chest exam findings: pulmonary fibrosis
inspection: Tachypnea palpation: ↓Movement percussion: Normal auscultation: Crackles or sounds like Velcro being pulled apart
chest exam findings: pulmonary edema
inspection: Tachypnea, labored respirations, cyanosis palpation: ↓Movement or normal movement percussion: Dull or normal depending on amount of fluid auscultation: Fine or coarse crackles at bases moving upward as condition worsens
chest exam findings: pleural effusion
inspection: Tachypnea, use of accessory muscles palpation: ↑Movement, ↑Fremitus above effusion. Absent fremitus over effusion percussion: Dull auscultation: Diminished or absent over effusion, egophony over effusion
chest exam findings: atelectasis
inspection: no change unless entire lobe, segment palpation: if small, no change. If large: ↓ movement, ↓ fremitus percussion: dull over affected area auscultation: crackles (may disappear with deep breaths). Absent breath sounds if large
chest exam findings: asthma exacerbation
inspection: prolonged expiration, tripod position, pursed lips palpation: decreased movement percussion: hyperresonance auscultation: wheezes, decreased breath sounds is ominous sign (severely diminished air movement)
chest exam findings: pneumonia
inspection: tachypnea, accessory muscle use, duskiness or cyanosis palpation: increased fremitus over affected area percussion: dull over affected areas auscultation: EARLY - bronchial sounds, LATER - crackles, rhonchi, egophony, whispered pectorliloquy
bronchial sounds
louder, higher pitched. Resemble air blowing through hollow pipe. Ratio is 2:3 with a gap between inspiration and expiration (pause between respiratory cycles). Heard along trachea in neck
bronchovesicular sounds
medium-pitch and intensity, heard anteriorly over bronchi on either side of sternum and posteriorly between scapulae. Inspiration and expiration are equal (1:1 ratio)
vesicular sounds
soft, low-pitched, gentle rustling sounds. Inspiration is three times longer than expiration (3:1 ratio)
Inspection: Finger clubbing
↑Depth, bulk, sponginess of distal portion of finger possible etiology: Chronic hypoxemia, cystic fibrosis, lung cancer, bronchiectasis.
