Chapter 27: Respiratory

The patient has been smoking one pack a day for 5 years and two packs a day for the last 2 years. How does the nurse document the smoking history in pack-years for this patient? Record your answer using a whole number. ________ years

9 years Rationale Pack-years is calculated as the number of packs smoked per day multiplied by the number of years the patient has smoked. For the first 5 years, the patient smoked 1 pack a day; 1 pack × 5 years = 5 pack-years. For the next 2 years, the patient smoked 2 packs a day; 2 pack × 2 years = 4 pack-years. Total pack years = 5 + 4 = 9 pack-years. p. 514

A patient with asthma reports shortness of breath. What is the nurse assessing when auscultating this patient's chest? Fremitus Oxygenation status Respiratory excursion Adventitious breath sounds

Adventitious breath sounds Rationale Adventitious sounds are additional breath sounds superimposed on normal sounds. They indicate pathologic changes in the lung. Fremitus is vibration and is not detected by auscultation. Oxygenation status cannot be detected specifically by auscultation. Respiratory excursion is detected by both observation of the movement of the chest and palpation as the patient inhales and exhales. p. 519

While auscultating the lungs of a 65-year-old patient, the nurse hears bronchial sounds at the lung edges. What does the nurse document this as? A normal finding A normal finding consistent with normal aging An abnormal finding consistent with pneumonia An abnormal finding consistent with chronic airway disease

An abnormal finding consistent with pneumonia Rationale When bronchial breath sounds are heard at the lung edges instead of over the trachea and main bronchus, they are abnormal. This increased sound occurs when the bronchial sounds are transmitted to an area of increased density, such as in patients with pneumonia, atelectasis, and tumors. Bronchovesicular, not bronchial, breath sounds heard in abnormal locations like the lung edges may indicate normal aging or an abnormality such as pulmonary consolidation and chronic airway disease. p. 519

What condition can be suspected in a patient if his or her eosinophil count is 700/mm 3? Asthma Tuberculosis Viral infection Bacterial infection

Asthma Rationale The normal eosinophil count ranges between 50 and 500/mm 3. An increased eosinophil count indicates possible asthma. An elevated monocyte count indicates possible tuberculosis. An elevated lymphocyte count indicates a viral infection. An increased count of neutrophils indicates the possibility of acute bacterial infection. p. 522, Chart 27-3

Which assessment finding is of greatest concern in a patient with emphysema? Barrel-shaped chest Ribs lying horizontal Hyperresonance to percussion of the chest Bronchial breath sounds heard at the bases

Bronchial breath sounds heard at the bases Rationale Bronchial breath sounds are not normally heard in the periphery and may indicate increased lung density, as in a tumor or an infective process such as pneumonia. The anteroposterior diameter is the same as the lateral-to-lateral or side-to-side diameter in a patient with emphysema, so he will generally have a barrel-shaped chest. Air-filled cavities, such as the lung, are hyperresonant to percussion. Air trapping causes the lungs in a patient with emphysema to lie in a horizontal direction. p. 519

The nurse relates continuous, adventitious breath sounds to which conditions? Select all that apply. Bronchitis Atelectasis Bronchospasm Interstitial fibrosis Pulmonary vessel engorgement

Bronchospasm Pulmonary vessel engorgement Rationale When a patient experiences bronchospasms and pulmonary vessel engorgement (cardiac asthma), the nurse should expect to auscultate wheezing upon both inspiration and expiration. Discontinuous, adventitious breath sounds include bronchitis, atelectasis, and interstitial fibrosis. These produce crackles and rales when the nurse auscultates the lung fields. p. 521, Table 27-5

A patient with COPD who has been receiving oxygen via nasal cannula is becoming increasingly dyspneic with increased use of accessory muscles to breathe. The nurse auscultates markedly diminished breath sounds in all lung fields. The nurse correctly notifies the provider and discusses which oxygen delivery method for this patient? Venturi mask Transtracheal oxygen Bi-level positive airway pressure (BiPAP) Continuous positive airway pressure (CPAP)

Continuous positive airway pressure (CPAP) Rationale The patient is experiencing atelectasis, as evidenced by diminished breath sounds, and would benefit from CPAP, which helps open alveoli and improve gas exchange. BiPAP is used to improve tidal volume, reduce respiratory rate, and relieve dyspnea. Transtracheal oxygen is used to provide oxygen without the discomfort of a mask or nasal cannula. A Venturi mask helps deliver a precise amount of oxygen but does not help open alveoli. p. 535

Which is a side effect of angiotensin-converting enzyme (ACE) inhibiting drugs on the respiratory system? Croup Cough Asthma Emphysema

Cough Rationale ACE inhibitors used for managing hypertension can cause a cough as a side effect. Croup, asthma, and emphysema are respiratory illnesses and are not side effects associated with ACE inhibitors.

The nurse auscultates popping, discontinuous sounds over the patient's anterior chest. How does the nurse classify these sounds? Crackles Rhonchi Wheeze Pleural friction rub

Crackles Rationale Crackles are described as a popping, discontinuous sound caused by air moving into previously deflated airways. The airways have been deflated due to the presence of fluids in the lungs, and crackles should be considered to be a sign of fluid overload. Rhonchi are low-pitched, coarse snoring sounds caused by fluid or secretions in larger airways. A pleural friction rub sounds grating, loud, or scratchy as inflamed surfaces of the pleura rub together. Wheezes are frequently referred to as musical or squeaky; they may occur on inspiration or on expiration and may be heard without a stethoscope as air rushes through narrowed airways. p. 521, Table 27-5

Which assessment findings are considered normal for a 79-year-old patient? Ability to cough and vital capacity increases Alveolar surface increases and residual volume decreases Anteroposterior diameter decreases and elasticity increases Effectiveness of the cilia decreases and risk of hypoxia increases

Effectiveness of the cilia decreases and risk of hypoxia increases Rationale Ciliary action decreases and risk of hypoxia increases as people age. Additionally, the alveolar surface, elasticity, vital capacity, and ability to cough decrease, and the residual volume and anteroposterior diameter increase. p. 513, Chart 27-1

A patient is diagnosed with chronic obstructive pulmonary disease (COPD). What laboratory values does the nurse expect? Select all that apply. Elevated eosinophils count Decreased neutrophils count Elevated red blood cell count Decreased partial pressure of arterial oxygen Decreased partial pressure of arterial carbon dioxide

Elevated eosinophils count Elevated red blood cell count Decreased partial pressure of arterial oxygen Rationale COPD is a condition that causes difficulty breathing due to the narrowing of airways. Eosinophilic airway inflammation occurs with COPD, which results in elevated levels of eosinophils. COPD produces hypoxic stimulus, which causes excessive production of erythropoietin and elevates red blood cell count. COPD reduces the level of oxygen in the blood and results in decreased partial pressure of arterial oxygen. Viral diseases like influenza decrease the neutrophil count. COPD elevates partial pressure of arterial carbon dioxide. Decreased partial pressure of arterial carbon dioxide is observed in hyperventilation/respiratory alkalosis. p. 522, Chart 27-3

The nurse is performing a chest assessment on a 70-year-old patient. The nurse observes a barrel shape to the patient's chest with a greater than 2-centimeter width of intercostal spaces. Upon percussion, the nurse notes hyperresonant sounds over all lung fields. These findings are characteristic of which respiratory condition? Pneumonia Lung cancer Emphysema Pneumothorax

Emphysema Rationale Emphysema is characterized by air trapping, which expands the lungs and the thoracic cavity. Patients will develop a barrel shape to the chest with an increased anteroposterior diameter and increased space between ribs. Hyperresonant sounds are sounds associated with air and not solid tissue. Assessments characteristic of pneumothorax are deviation of the trachea to the affected side, increased respiratory distress, and absent breath sounds on the affected side. Assessments for lung cancer and pneumonia would include absent or diminished breath sounds over the affected area(s) and cough. p. 518

While reviewing the laboratory reports of a 76-year-old patient, the nurse finds decreased alveolar surface area and diffusion capacity. A physical assessment reveals that the patient has a decreased ability to cough. What would be the most effective nursing intervention provided to the patient? Assess for breathlessness due to hypoxia Encourage increased rest periods during exercise Encourage the patient to cough and take deep breaths Assess the patient's level of consciousness and cognition

Encourage the patient to cough and take deep breaths Rationale A decrease in alveolar surface area, diffusion capacity, and ability to cough are due to age-related physiological changes in the alveoli. Therefore, the patient should be encouraged to cough and take deep breaths to reduce the risk of mechanical or infectious respiratory complications. A patient suffering from exercise tolerance should be assessed for manifestations of hypoxia (such as breathlessness) because early detection prevents further complications. Chest wall elasticity decreases with age, and the patient may develop less tolerance to exercise; increasing the rest period in between exercises is advised because the patient may be at risk for hypoxia. Assessing the consciousness and cognition in the patient is important if the patient shows signs of confusion or other mental disabilities. p. 513, Chart 27-1

In assessing the patient's respiratory status, blood gas test results reveal pH of 7.50, PaO 2 of 99, PaCO 2 of 29, and HCO 3 - of 22. What action does the nurse need to take first? Provide oxygen support. Call the health care provider. Encourage the patient to slow his breathing rate. Nothing; these results are within the normal range.

Encourage the patient to slow his breathing rate. Rationale The arterial blood gases (ABGs) indicate respiratory alkalosis, which is commonly caused by hyperventilation; encouraging the patient to slow down his or her breathing rate may help the patient return to normal breathing and may correct this abnormality. This situation is not an emergency condition and does not require that the health care provider be called. The patient's PaO 2 is within normal limits, but it is important for the nurse to assess the patient and not just look at the numbers. p. 522, Chart 27-3

The nurse is assessing the smoking habits of a patient being treated for a respiratory disorder caused by tobacco smoke. What tasks should the nurse perform to assess the patient? Select all that apply. Select all that apply Get a chest x-ray of the patient. Get the smoking history of the patient. Check whether the patient also chews tobacco. Know more about the cigarette brand being used. Check about direct exposure to secondhand smoke.

Get the smoking history of the patient. Check about direct exposure to secondhand smoke. Rationale Assessment of smoking habits starts with getting the details of the patient's smoking history, which include the number of cigarettes smoked daily, the duration of the habit, and the patient's age when he or she started smoking. The amount of exposure to secondhand smoke should also be assessed. An x-ray does not form part of the smoking habit assessment. Neither tobacco chewing habits nor the brand of cigarettes will reveal information about the duration and extent of damage caused by smoking. p. 514

What information about a patient with a respiratory disorder holds more relevance during a focused health assessment? Hobbies Vital statistics Food preferences Exercise schedule

Hobbies Rationale Respiratory problems may occur due to exposure to inhalation irritants found in the environment. The patient would be exposed to harmful chemicals and irritants if he or she has hobbies such as painting, ceramics, model airplanes, refinishing furniture, or woodworking. The nurse may take the patient's vital statistics, food preferences, and exercise schedule as part of a general fact-finding assessment. p. 515

A patient is on bupropion as part of a drug therapy for smoking cessation. Which information about the drug should the nurse provide to the patient? It may cause hallucinations. It may cause loss of appetite. It may make the throat go dry. It may cause excessive perspiration.

It may cause hallucinations. Rationale Bupropion can cause manic behavior and hallucinations. Loss of appetite, throat dryness, and excessive perspiration are not related to bupropion. p. 515

The nurse is performing auscultation to assess the lungs of a patient. What actions does the nurse take? Select all that apply. Listens to a full respiratory cycle Asks the patient to breathe through the nose Places the stethoscope over the area to be auscultated Listens from the lung apices vertically to the lung bases Instructs the patient to breathe deeply and slowly through the mouth

Listens to a full respiratory cycle Places the stethoscope over the area to be auscultated Instructs the patient to breathe deeply and slowly through the mouth Rationale The nurse places the stethoscope over the area that needs to be auscultated. The stethoscope is pressed firmly over the chest wall, and the patient is asked to breathe deeply and slowly through the mouth. The nurse listens to a full respiratory cycle, noting the quality and intensity of the breath sounds. The patient is not asked to breathe through the nose because this transmits turbulent sounds to the lungs. The nurse begins auscultation from the lung apices and moves from side to side through the intercostal spaces to the lung bases. The side-to-side method allows the nurse to compare one lung with the other. p. 519

The nurse educator teaches a student nurse about auscultation of the lungs. Which action performed by the student nurse indicates a need for further education? Listens to the sound over bony structures Asks the patient to sit in an upright position Instructs the patient to breathe slowly through the mouth Begins auscultation from lung apices and moving towards intercostal spaces

Listens to the sound over bony structures Rationale Auscultation is performed to identify fluid, mucus, or obstruction in the respiratory system. The nurse should avoid performing auscultation over bony structures, as it interferes with the sound quality. An upright position optimizes airflow and allows chest expansion, which facilitates clear respiratory sounds during auscultation. Breathing slowly through an open mouth prevents transmission of turbulent sound and helps the examiner hear the sounds more clearly. Beginning auscultation from lung apices and moving toward intercostal spaces to the lung bases helps compare one lung with the other at the same level. p. 519

In instructing an older patient to help prevent age-related respiratory system disease, what does the nurse tell the patient to do? Maintain a regular exercise program. Use an incentive spirometer every day. Report early signs of respiratory infection. Wear a mask to prevent inhalation of irritants.

Maintain a regular exercise program. Rationale Maintaining health and fitness helps to keep the respiratory system musculature healthy and improves respiratory function. Reporting early signs of respiratory infection can help minimize disease but does not prevent it. Incentive spirometry is used when the risk of respiratory infection is high, as with surgery. Wearing a mask is indicated if the patient is in an area or situation where respiratory irritants are prevalent. p. 513, Chart 27-1

A patient with chronic lung disease who is undergoing an admission assessment reports moderate breathlessness occurring with activity that resolves with rest. What does the nurse recommend for this patient as part of outpatient management? No activity restriction May work in sedentary job Requires assistance for all care May need assistance for activities of daily living (ADLs)

May need assistance for activities of daily living (ADLs) Rationale The patient describes a level 2 performance of ADLs and may require assistance for normal activities or may be able to function independently with rest and by pacing activities. A patient without any breathlessness (level 4 performance) has no activity restrictions. Those with level 3 performance are independent but must work in sedentary jobs. Those with level 0 or 1 performance require assistance with all ADLs. p. 517, Table 27-2

What is the nature of sputum in a smoker with chronic bronchitis? Thin Thick Watery Mucoid

Mucoid Rationale The nature of sputum in a smoker with chronic bronchitis is mucoid. Smokers with chronic bronchitis do not have thin, thick, or watery sputum in nature. p. 516

The nurse is working in an urgent care clinic. Which patient needs to be evaluated first by the nurse? Patient with sore throat and fever of 39° C oral Patient who is short of breath after walking up two flights of stairs Patient with soreness of the arm after receiving purified protein derivative (PPD) (Mantoux) skin test Patient who is speaking in three-word sentences and has an Spo 2 of 90% by pulse oximetry

Patient who is speaking in three-word sentences and has an Spo 2 of 90% by pulse oximetry Rationale A patient should be able to speak in sentences of more than three words, and an Spo 2 of 90% indicates hypoxemia that requires intervention on the part of the nurse. Shortness of breath after walking up two flights of stairs may not be an emergency. Although not a usual finding, the arm may be sore after a skin test is performed. Sore throat and fever are symptoms of infection that require further evaluation but not emergently. pp. 520-521

The nurse hears loud, rough, grating, scratching sounds on auscultation in a patient with tuberculosis. How does the nurse document this finding? Wheeze Rhonchus Coarse crackles Pleural friction rub

Pleural friction rub Rationale A pleural friction rub is heard as a loud, rough, grating, scratching sound on auscultation. It is caused by inflamed surfaces of the pleura rubbing together and is often associated with pain on deep inspirations. Wheezing is squeaky, musical, continuous sounds associated with air rushing through narrowed airways and can be heard without a stethoscope. Rhonchi are pitched, coarse, continuous snoring sounds which arise from the large airways. Coarse crackles are lower-pitched, coarse, discontinuous rattling sounds caused by fluid or secretions in large airways and are associated with bronchitis and pneumonia. p. 521, Table 27-5

While auscultating breath sounds, the nurse notes increased vocal resonance. Which condition is associated with this finding? Asthma Pleural rub Pneumonia Subcutaneous crepitus

Pneumonia Rationale The presence of pneumonia, atelectasis, pleural effusion, tumor, or abscess causes increased vocal resonance. Clinically, asthma, pleural friction rub, and subcutaneous crepitus will not increase vocal resonance on auscultation. p. 519

The nurse is assessing the hemoglobin saturation of a patient after surgery using pulse oximetry. What are the possible causes for false low readings? Select all that apply. Presence of edema Decreased hemoglobin Decreased ambient light Presence of hypothermia Decreased peripheral flow

Presence of edema Decreased hemoglobin Presence of hypothermia Decreased peripheral flow Rationale Hypothermia, decreased peripheral flow, edema, and decreased hemoglobin can contribute to false low pulse oximetry readings. Pulse oximetry can detect desaturation before manifestations such as pale mucosa or blue nail beds occur. When patients have any degree of impaired peripheral blood flow, such as in edema or decreased hemoglobin, the most accurate place to test oxygen saturation is on the forehead. Decreased ambient light does not affect the reading, but sunlight or infra-red light can cause low readings. Changing the position of the sensor or covering it with a fingertip cut from a glove may help accuracy if too much light is present. p. 523

A patient's spouse calls the nurse to the room because the pulse oximeter's alarm is going off. The reading shows 82%. The patient is talking to his visitors and has unlabored respirations and pink color. What is the best action for the nurse to take? Notify the Rapid Response Team immediately. Apply supplemental oxygen by mask or nasal cannula. Reposition the pulse oximeter probe and recheck the values. Assess the patient's lips and nail beds for cyanosis and auscultate breath sounds.

Reposition the pulse oximeter probe and recheck the values. Rationale A low oxygen saturation is an emergency, but there are many causes of a low reading with pulse oximetry. The value should be verified before other interventions are implemented. Once the pulse oximetry equipment is determined to be working, the nurse would assess the patient's lips and nail beds and auscultate breath sounds, then apply oxygen. The Rapid Response Team is called when respiratory failure is imminent. p. 523

Which test helps to assess the amount of air remaining in the lungs at the end of a full, forced exhalation? Residual volume Total lung capacity Forced vital capacity Functional residual capacity

Residual volume Rationale A residual volume test is used to determine the amount of air remaining in the lungs at the end of a full, forced exhalation. Total lung capacity is performed to determine the amount of air in the lungs at the end of maximum inhalation. Forced vital capacity is performed to determine the maximum amount of air that can be exhaled as quickly as possible after maximum inspiration. Functional residual capacity is performed to determine the amount of air remaining in the lungs after normal expiration. p. 525, Table 27-6

The nurse is caring for a patient with bacterial pneumonia. What kind of sputum does the nurse anticipate in the patient? Mucoid sputum Pink, frothy sputum Rust-colored sputum Hemoptysis (bloody sputum)

Rust-colored sputum Rationale The patient with bacterial pneumonia has rust-colored sputum. Smokers with chronic bronchitis have mucoid sputum. Pink, frothy sputum is common in patients with pulmonary edema. Hemoptysis is seen patients with chronic bronchitis or lung cancer. p. 516

What sensation is influenced by the respiratory system? Sense of smell Sense of taste Sense of touch Sense of vision

Sense of smell Rationale The sense of smell (or olfactory sense) is influenced by the respiratory system. The nose is an olfactory organ located in the upper respiratory tract. p. 509

How does the nurse identify pulmonary pain in a patient? The patient experiences a "rubbing" sensation. The patient states that pain is intense and "crushing." The patient feels the pain radiating to the arm and shoulder. The patient experiences an increase in pain when the area is touched.

The patient experiences a "rubbing" sensation. Rationale The patient with pulmonary pain experiences a "rubbing" sensation caused by the inflamed pleural layers that line the lungs rubbing against each other every time the lungs expand to breathe in air. Cardiac pain usually radiates to the arm and shoulder. It is intense and "crushing" due to a reduction of blood flow through the heart vessels resulting in the death of cardiac muscle. The patient with pulmonary pain is not affected when the area is touched or pressed. p. 517

Which health risk is the LGBT (lesbian, gay, bisexual, transgender) community more prone to as compared to their heterosexual counterparts? Skin cancer Liver cancer Throat cancer Stomach cancer

Throat cancer Rationale LGBT people who smoke are more vulnerable to throat and lung cancers. Skin cancer is not caused by smoking; it arises from abnormality in the skin cells. Liver cancer is caused by alcohol intoxication. Stomach cancer is caused by stomach inflammation. p. 514

What is one of the purposes of oxygen therapy? To cure the problem To stop the disease process To have an acceptable blood oxygen level To use the highest fraction of inspired oxygen

To have an acceptable blood oxygen level Rationale One of the purposes of oxygen therapy is to have an acceptable blood oxygen level without causing harmful side effects. Oxygen therapy cannot cure a problem or stop a disease process. The lowest fraction of inspired oxygen is used. p. 529

Which areas of the body are acceptable for testing oxygen saturation levels? Select all that apply. Toes Nose Wrists Fingers Earlobes

Toes Nose Fingers Earlobes Rationale Oxygen saturation is measured through pulse oximetry. To obtain this measurement, the probe may be placed on the fingers, toes, earlobes, nose, and forehead. These body areas are the most peripheral parts of the body and provide an accurate measurement of hemoglobin saturation. The wrists are not an appropriate place for pulse oximetry because they may provide false readings. p. 523

Which sound is an expected finding when auscultating the peripheral lung fields? Vesicular Bronchovesicular Bronchial tubular Bronchial tracheal

Vesicular Rationale The nurse should expect to auscultate vesicular breath sounds in the peripheral lung fields. Vesicular breath sounds like leaves rustling in the trees. Inspiration should be longer than expiration. Bronchovesicular sounds are heard over major bronchi, where there are fewer alveoli located. When listening to bronchovesicular breath sounds, inspiration is equal to expiration. Bronchial tubular and bronchial tracheal sounds are heard over the trachea and larynx. The sounds are hollow due to the size of the main stem bronchi, and expiration is longer than inspiration. p. 519