Chapter 8: PrepU - Nursing Assessment: Respiratory Function

A client arrives at the physician's office stating 2 days of febrile illness, dyspnea, and cough. Upon assisting the client into a gown, the nurse notes that the client's sternum is depressed, especially on inspiration. Crackles are noted in the bases of the lung fields. Based on inspection, which will the nurse document? 1- The client has a funnel chest. 2- The client has chronic respiratory disease. 3- The client has pneumonia in the bases. 4- The client needs a cough suppressant.

1

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? 1- "Anytime there is a chronic disease process it is hard for the person to breathe." 2- "Having a chronic respiratory disease scars the lung and affects the effort it takes to breathe." 3- "In this particular case your family member is just overly tired and having problems breathing." 4- "Conditions such as chronic bronchitis cause thickening of the bronchial mucosa so it makes it harder to breathe."

4

A patient is having her tonsils removed. The patient asks the nurse what function the tonsils serve. Which of the following would be the most accurate response? 1- "The tonsils aid in digestion." 2- "The tonsils help to guard the body from invasion of organisms." 3- "The tonsils contain nerves that provoke sneezing." 4- "The tonsils regulate the airflow to the bronchi."

2

The term for the volume of air inhaled and exhaled with each breath is 1- residual volume. 2- tidal volume. 3- vital capacity. 4- expiratory reserve volume.

2

A 15-year-old boy with a history of asthma is undergoing lung function testing after experiencing a series of recent exacerbations. Which of the following instructions would facilitate measurement of the child's inspiratory reserve volume (IRV)? 1- "Take normal, comfortable breaths until I ask you to stop." 2- "Force as much air out of your lungs as you can and then take the deepest breath that you can." 3- "I want you to take a normal breath in and then breathe in as deeply as you possibly can." 4- "Breathe out like you normally would and then immediately breathe out as much as you're able to."

3

During a preadmission assessment, the nurse finds increased tactile fremitus. She knows this sign is consistent with which of the following diagnoses? 1- Bronchitis 2- Emphysema 3- Atelectasis 4- Pneumonia

4

A patient diagnosed with diabetic ketoacidosis would be expected to have which type of respiratory pattern? 1- Kussmaul respirations 2- Cheyne-Stokes 3- Biot's respirations 4- Apnea

1

A patient with sinus congestion complains of discomfort when the nurse is palpating the supraorbital ridges. The nurse knows that the patient is referring to which sinus? 1- Frontal 2- Ethmoidal 3- Maxillary 4- Sphenoidal

1

A client has recently been diagnosed with malignant lung cancer. The nurse is calculating the client's smoking history in pack-years. The client reports smoking two packs of cigarettes a day for the past 11 years. The nurse correctly documents the client's pack-years as 1- 22. 2- 11. 3- 10. 4- 5.

1

A nurse is caring for a client after a lung biopsy. Which assessment finding requires immediate intervention? 1- Respiratory rate of 44 breaths/minute 2- Oxygen saturation level of 96% on 3 L of oxygen 3- Client stating pain level of 7 out of 10 that decreases with pain medication 4- Client dozing when left alone but awakening easily

1

A nurse is examining a client's chest. During the exam, the nurse palpates what feels like bubbles under the clent's chest muscles. Which term would the nurse use when documenting this finding? 1- crepitus 2- crackles 3- rhonchi 4- wheeze

1

A patient's lung volumes and capacities were assessed to help determine the cause of a respiratory problem. Which of the following findings are indicative of chronic obstructive pulmonary disease (COPD)? 1- Vital capacity of 3,000 mL 2- Expiratory reserve volume of 1,100 mL 3- Residual volume of 1,200 mL 4- Functional residual capacity of 2,300 mL

1

A thorascentesis is performed to obtain a sample of pleural fluid or a biopsy specimen from the pleural wall for diagnostic purposes. What does bloody fluid results indicate? 1- Trauma 2- Infection 3- Malignancy 4- Emphysema

1

An emergency department (ED) nurse is caring for a patient complaining of dyspnea. The nurse assesses the patient's chest and hears wheezing throughout the lung fields. What might this indicate? 1- The patient is in bronchospasm. 2- The patient has pneumonia. 3- The patient needs physiotherapy. 4- The patient has a hemothorax.

1

High or increased compliance occurs in which disease process? 1- Emphysema 2- Pneumothorax 3- Pleural effusion 4- ARDS

1

If concern exists about fluid accumulation in a client's lungs, what area of the lungs will the nurse focus on during assessment? 1- Bilateral lower lobes 2- Anterior bronchioles 3- Posterior bronchioles 4- Left lower lobe

1

In a patient diagnosed with increased intracranial pressure (IICP), the nurse would expect to observe which of the following respiratory rate or depth? 1- Bradypnea 2- Tachypnea 3- Hypoventilation 4- Hyperventilation

1

The nurse is assessing the lungs of a patient diagnosed with pulmonary edema. Which of the following would be expected upon auscultation? 1- Crackles at lung bases 2- Egophony 3- Absent breath sounds 4- Bronchial breath sounds

1

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? 1- type II cells 2- type I cells 3- type IV cells 4- type III cells

2

Pink, frothy sputum may be an indication of 1- a lung abscess. 2- pulmonary edema. 3- an infection. 4- bronchiectasis.

2

The clinical finding of pink, frothy sputum may be an indication of which condition? 1- Lung abscess 2- Pulmonary edema 3- Infection 4- Bronchiectasis

2

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: 1- Posterior surface of the left side of the chest, near the sixth rib. 2- Anterior surface of the right side of the chest, between the fourth and fifth rib. 3- Posterior surface of the right side of the chest, near T3. 4- Anterior surface of the left side of the chest, near the sixth rib.

2

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? 1- Crackles 2- Pleural friction rub 3- Rhonchi 4- Bronchial

3

The nurse is caring for a client with an exacerbation of COPD and scheduled for pulmonary function studies using a spirometer. Which client statement would the nurse clarify? 1- "My study is scheduled for 10 AM, several hours after I eat." 2- "I brought comfortable clothes and shoes for the test." 3- "I am ordered a bronchodilator to note lung improvement following use." 4- "I will breathe in through my mouth and out through my nose."

4

In relation to the structure of the larynx, the cricoid cartilage is 1- the only complete cartilaginous ring in the larynx. 2- used with the thyroid cartilage in vocal cord movement. 3- the largest of the cartilage structures. 4- the valve flap of cartilage that covers the opening to the larynx during swallowing.

1

Which hollow tube transports air from the laryngeal pharynx to the bronchi? 1- trachea 2- larynx 3- bronchioles 4- pharynx

1

Which of the following clinical manifestations should a nurse monitor for during a pulmonary angiography, which indicates an allergic reaction to the contrast medium? 1- Difficulty in breathing 2- Hematoma 3- Absent distal pulses 4- Urge to cough

1

You are assessing the respiratory system of a client just admitted to your unit. What do you know to assess in addition to the physical and functional issues related to breathing? 1- How these issues affect the client's quality of life 2- How these issues affect the relationships in the client's life 3- How these issues affect the client's effort to breathe 4- How these issues affect the client's ability to function

1

The nurse is providing care for a number of patients who are receiving treatment for health problems that have a respiratory etiology. Which of the following patients is most likely to benefit from the administration of a PO or IV diuretic? 1- A patient who presents with a barrel chest 2- A patient who has crackles on auscultation 3- A patient who has a sibilant wheeze 4- A patient who has recently complained of chest pain

2

While assessing for tactile fremitus, the nurse palpates almost no vibration. Which of the following conditions in this client's history will account for this finding? 1- Pneumonia 2- Funnel chest 3- Emphysema 4- Pigeon chest

3

While conducting the physical examination during assessment of the respiratory system, which conditions does the nurse assess by inspecting and palpating the trachea? 1- Evidence of exudate 2- Color of the mucous membranes 3- Deviation from the midline 4- Evidence of muscle weakness

3

A nurse is preparing a client for bronchoscopy. Which instruction should the nurse give to the client? 1- Don't walk. 2- Don't cough. 3- Don't talk. 4- Don't eat.

4

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? 1- Bacterial pneumonia 2- Bronchogenic carcinoma 3- Lung infarction 4- Pleurisy

4

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? 1- Atelectasis 2- Infective process 3- Tumor 4- Pulmonary embolism

4

What would the instructor tell the students purulent fluid indicates? 1- Cancer 2- Infection 3- Inflammation 4- Heart failure

2

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? 1- Rales 2- Crackles 3- Wheezes 4- Rhonchi

3

The instructor of the pre-nursing physiology class is explaining respiration to the class. What does the instructor explain is the main function of respiration? 1- To exchange oxygen and CO2 between the atmospheric air and the blood and between the blood and the cells 2- To move CO2 out of the atmospheric air and into the expired air 3- To move O2 out of the atmospheric air and into the retained air 4- To exchange atmospheric air between the blood and the cells

1

What finding by the nurse may indicate that the client has chronic hypoxia? 1- Crackles 2- Peripheral edema 3- Clubbing of the fingers 4- Cyanosis

3

A patient presented to a clinic with a cough suggestive of pneumonia. Which of the following describes the expected characteristic of the cough? 1- Dry and slightly irritating 2- High-pitched and irritating 3- Brassy and dry 4- Hacking with sputum production

4

The nurse is caring for a client with a decrease in airway diameter causing airway resistance. The client experiences coughing and mucus production. Upon lung assessment, which adventitious breath sounds are anticipated? 1- Crackles 2- Rhonchi 3- Rubs 4- Wheezes

4

A hospitalized patient is asked to describe his dyspnea as objectively as possible. He states that he has to stop to breathe after walking about 100 yards on a level path. On a grade of 0 to 4, the nurse documents his symptoms as a grade: 1- One 2- Two 3- Three 4- Four

3

Lung compliance (the ability of the lungs to stretch) is a physical factor that affects ventilation. A nurse is aware that a patient who has lost elasticity in the lung tissue has a condition known as: 1- Atelectasis 2- Pulmonary edema 3- Emphysema 4- Pleural effusion

3

The nurse is caring for a client diagnosed with pneumonia. The nurse assesses the client for tactile fremitus by completing which action? 1- Asking the client to repeat "ninety-nine" as the nurse's hands move down the client's thorax 2- Asking the client to say "one, two, three" while the nurse auscultates the lungs 3- Instructing the client to take a deep breath and hold it while the diaphragm is percussed 4- Placing the thumbs along the costal margin of the chest wall and instructing the client to inhale deeply

1

The nurse is caring for a client who is in respiratory distress. The physician orders arterial blood gases (ABGs) to determine various factors related to blood oxygenation. What site can ABGs be obtained from? 1- A puncture at the radial artery 2- The trachea and bronchi 3- The pleural surfaces 4- A catheter in the arm vein

1

The nurse is interviewing a patient who says he has a dry, irritating cough that is not "bringing anything up." What medication should the nurse question the patient about taking? 1- Angiotensin converting enzyme (ACE) inhibitors 2- Aspirin 3- Bronchodilators 4- Cardiac glycosides

1

The nurse is studying for a physiology test over the respiratory system. What should the nurse know about central chemoreceptors in the medulla? 1- They respond to changes in CO2 levels and hydrogen ion concentrations (pH) in the cerebrospinal fluid. 2- They respond to changes in the O2 levels in the brain. 3- They respond to changes in CO2 levels in the brain. 4- They respond to changes in O2 levels and bicarbonate levels in the cerebrospinal fluid.

1

Understanding pulmonary physiology, what characteristic would the nurse expect to result in decreased gas exchange in older adults? 1- alveolar walls containing fewer capillaries 2- thickening alveolar walls 3- Increased pulmonary elasticity 4- Reduced numbers of alveoli

1

What is the primary function of the larynx? 1- producing sound 2- protecting the lower airway from foreign objects 3- facilitating coughing 4- preventing infection

1

Your client is scheduled for a bronchoscopy to visualize the larynx, trachea, and bronchi. What precautions would you recommend to the client before the procedure? 1- Abstain from food for at least 6 hours before the procedure. 2- Avoid sedatives or narcotics as they depress the vagus nerve. 3- Avoid atropines as they dry the secretions. 4- Practice holding the breath for short periods.

1

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.) 1- A mask will be placed over the nose and mouth during the test. 2- The patient will be expected to lie under the camera. 3- The imaging time will amount to 20 to 40 minutes. 4- The patient will be expected to be NPO for 12 hours prior to the procedure. 5- An injection will be placed into the lung during the procedure.

1,2,3

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? 1- Asthma 2- Emphysema 3- Tuberculosis 4- Chronic bronchitis

2

A black client with asthma seeks emergency care for acute respiratory distress. Because of this client's dark skin, the nurse should assess for cyanosis by inspecting the: 1- lips. 2- mucous membranes. 3- nail beds. 4- earlobes.

2

A 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? 1- Client can perform incentive spirometry. 2- Lungs are clear on auscultation. 3- Respiratory rate is 12 to 18 breaths per minute. 4- Client reports no chest pain.

2

A nurse assesses a client's respiratory status. Which observation indicates that the client is having difficulty breathing? 1- Diaphragmatic breathing 2- Use of accessory muscles 3- Pursed-lip breathing 4- Controlled breathing

2

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 1- pleural friction rub. 2- crackles. 3- sonorous wheezes. 4- sibilant wheezes.

1

A client appears to be breathing faster than during the last assessment. Which of the following interventions should the nurse perform? 1- Inquire if there have been any stressful visitors. 2- Assist the client to lie down. 3- Count the rate of respirations. 4- Assess the radial pulse.

3

Upon palpation of the sinus area, what would the nurse identify as a normal finding? 1- Light not going through the sinus cavity 2- Pain sensation behind the eyes 3- Tenderness during palpation 4- No sensation during palpation

4

A nurse is concerned that a client may develop postoperative atelectasis. Which nursing diagnosis would be most appropriate if this complication occurs? 1- Ineffective airway clearance 2- Impaired gas exchange 3- Decreased cardiac output I 4- mpaired spontaneous ventilation

2

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? 1- Respiratory rate 2- Cyanosis 3- Son's statement 4- Crackles

2

An acutely ill patient is in a supine position. What approach should the nurse take to assess the patient's lung fields for a patient in this position? 1- Inform the health care provider that the patient is in a supine position and anticipate an order for a portable chest X-ray. 2- Turn the patient on his or her side to assess all lung fields, so that dependent areas can be assessed for breath sounds. 3- Avoid turning the patient, and assess the accessible breath sounds from the anterior chest wall. 4- Obtain a pulse oximetry reading and, if the reading is low, reposition the patient and auscultate breath sounds.

2

For air to enter the lungs (process of ventilation), the intrapulmonary pressure must be less than atmospheric pressure so air can be pulled inward. Select the movement of respiratory muscles that makes this happen during inspiration. 1- Lungs are pulled up and pushed back against the thoracic cage. 2- Diaphragm contracts and elongates the chest cavity. 3- Intercostals muscles relax to allow for expansion. 4- Anteroposterior rib diameter decreases.

2

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? 1- Placement of the probe on an earlobe 2- Diagnosis of peripheral vascular disease 3- Reduced lighting in the room 4- Increased temperature of the room

2

The nurse is admitting a client who just had a bronchoscopy. Which assessment should be the nurse's priority? 1- Medication allergies 2- Swallow reflex 3- Presence of carotid pulse 4- Ability to deep breathe

2

The nurse is caring for a client in the immediate post-thoracentesis period. In which position is the client placed? 1- In the supine position 2- Lying on the unaffected side 3- In the high Fowler's position 4- Prone with a pillow under the head

2

The nurse is providing care for a 60-year-old patient who has been admitted for the treatment of community-acquired pneumonia. The nurse reads in the patient's chart that he has an 80 pack-year history of cigarette smoking. During health education about smoking cessation, the patient tells the nurse that he began smoking as a 20-year-old when he was conscripted into the army. What conclusion can the nurse draw from these data? 1- The patient smokes four packs of cigarettes each day. 2- The patient has been smoking two packs a day for most of his adult life. 3- The patient is extremely unlikely to be able to stop smoking. 4- The patient is unaware of the health consequences of smoking.

2

The nurse is reviewing the blood gas results for a patient with pneumonia. What arterial blood gas measurement best reflects the adequacy of alveolar ventilation? 1- PaO2 2- PaCO2 3- pH 4- SaO2

2

What is the difference between respiration and ventilation? 1- Ventilation is the process of gas exchange. 2- Ventilation is the movement of air in and out of the respiratory tract. 3- Ventilation is the process of getting oxygen to the cells. 4- Ventilation is the exchange of gases in the lung.

2

A client arrived in the emergency department with a sharp object penetrating the diaphragm. When planning nursing care, which nursing diagnosis would the nurse identify as a priority? 1- Acute Pain 2- Potential for Infection 3- Impaired Gas Exchange 4- Ineffective Airway Clearance

3

Computed tomography of a patient's chest is suggestive of a malignancy, but these results are not conclusive. As a result, the patient has been scheduled for a bronchoscopy. What patient education should the nurse provide for this patient regarding this diagnostic procedure? 1- "The care team will likely give you a general anesthetic for your bronchoscopy." 2- "Your doctor will probably instill a contrast solution into your lungs to aid visualization." 3- "We'll monitor you closely after the procedure, especially until your gag reflex returns." 4- "You won't be able to swallow solid food for a day or two after the procedure."

3

The client has just had an invasive procedure to assess the respiratory system. What does the nurse know should be assessed on this client? 1- Watery sputum 2- Loss of consciousness 3- Respiratory distress 4- Masses in pleural space

3

The nurse has assessed a patient's pulse, temperature, blood pressure, and respiratory rate and is now measuring the patient's oxygenation by pulse oximetry. The nurse understands that this assessment finding is based on: 1- The ratio of oxygen to carbon dioxide in arterial blood 2- The amount of oxygen dissolved in blood plasma 3- The saturation of hemoglobin by oxygen molecules 4- The quantity of free oxygen in arterial blood

3

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? 1- Raised temperature in the affected limb 2- Excessive capillary refill 3- Absent distal pulses 4- Flushed feeling in the client

3

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. What is the reason the client with suspected lung cancer would undergo magnetic resonance imaging (MRI)? 1- Tumor densities can be seen with radiolucent images. 2- Narrow-beam x-ray can scan successive lung layers. 3- Lung blood flow can be viewed after a radiopaque agent is injected. 4- MRI can view soft tissues and can help stage cancers.

4

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? 1- Acute respiratory obstruction 2- Adult respiratory distress syndrome 3- Pneumothorax 4- Asthma

4

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? 1- "I will feel a dull pain when the catheter is introduced." 2- "I will feel light-headed when the contrast medium is introduced." 3- "I will feel waves of nausea throughout the procedure." 4- "I will feel warm and an urge to cough."

4

What is the purpose of the vascular and ciliated mucous lining of the nasal cavities? 1- Cool and dry expired air 2- Move mucus to the back of the throat 3- Moisten and filter expired air 4- Warm and humidify inspired air

4

When assessing a client, which adaptation indicates the presence of respiratory distress? 1- Respiratory rate of 14 breaths per minute 2- Productive cough 3- Sore throat 4- Orthopnea

4

Which respiratory volume is the maximum volume of air that can be inhaled after maximal expiration? 1- Tidal volume 2- Expiratory reserve volume 3- Residual volume 4- Inspiratory reserve volume

4