Chapter 8 Respiratory Function
Inspection of a patient's skin color is part of the assessment of the integumentary system. Cyanosis, which is a late indicator of hypoxia, is present when the unoxygenated hemoglobin level is:
5 g/dL Explanation: Normal hemoglobin is approximately 15 g/dL. Cyanosis appears when a full *one-third* of the hemoglobin is deoxygenated.
What is the difference between respiration and ventilation?
Ventilation is the movement of air in and out of the respiratory tract.
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?
"I will feel warm and an urge to cough."
Following a chest X-ray, a patient has been diagnosed with a pleural effusion. The care team has concluded that the quantity of fluid in the patient's intrapleural space necessitates thoracentesis. What patient education should the nurse provide in anticipation of this procedure?
"It's very important that you remain still while the doctor is performing the procedure."
Which of the following are age-related structural and functional changes that occur in the respiratory system? Select all that apply.
-Decreased elasticity of the alveolar sacs -Increased residual volume -Increased diameter of alveolar ducts -Increased thickness of alveolar sacs
The nurse is performing a physical assessment on a client who has a history of a respiratory infection. Which documentation, completed by the nurse, indicates the resolution of the infection? Select all that apply.
-Lung fields documented as clear in the bases. -Palpable vibrations over the chest wall when the client speaks. -Bronchovesicular sounds heard over the upper lung fields.
Normally, approximately what percentage of the blood pumped by the right ventricle does not perfuse the alveolar capillaries?
2%
A nurse understands that a safe but low level of oxygen saturation provides for adequate tissue saturation while allowing no reserve for situations that threaten ventilation. What is a safe but low oxygen saturation level for a patient?
95%
A nurse would question the accuracy of a pulse oximetry evaluation in which of the following conditions?
A client experiencing hypothermia
You are 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?
A puncture at the radial artery
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?
Absent distal pulses
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?
Abstain from food for at least 6 hours before the procedure.
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?
Angiotensin converting enzyme (ACE) inhibitors *Common causes of cough include asthma, gastrointestinal reflux disease, infection, aspiration, and side effects of medications, such as angiotensin converting enzyme (ACE) inhibitors. The other medications listed are not associated with causing a cough.
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?
Angiotensin converting enzyme (ACE) inhibitors Explanation: Common causes of cough include asthma, gastrointestinal reflux disease, infection, aspiration, and side effects of medications, such as angiotensin converting enzyme (ACE) inhibitors. The other medications listed are not associated with causing a cough.
The nurse is caring for a patient diagnosed with pneumonia. The nurse will assess the patient for tactile fremitus by completing which of the following?
Asking the patient to repeat "ninety-nine" as the nurse's hands move down the patient's thorax
The nurse is caring for a patient with recurrent hemoptysis who has undergone a bronchoscopy. Immediately following the procedure, the nurse should complete which of the following?
Assess the patient for a cough reflex.
The nurse assessed a 28-year-old woman who was experiencing dyspnea severe enough to make her seek medical attention. The history revealed no prior cardiac problems and the presence of symptoms for 6 months' duration. On assessment, the nurse noted the presence of both inspiratory and expiratory wheezing. Based on this data, which of the following diagnoses is likely?
Asthma
The nurse assessed a 28-year-old woman who was experiencing dyspnea severe enough to make her seek medical attention. The history revealed no prior cardiac problems and the presence of symptoms for 6 months' duration. On assessment, the nurse noted the presence of both inspiratory and expiratory wheezing. Based on this data, which of the following diagnoses is likely?
Asthma Explanation: The presence of both inspiratory and expiratory wheezing usually signifies asthma if the individual does not have heart failure. Sudden dyspnea is an indicator of the other choices.
Which of the following is a deformity of the chest that occurs as a result of over inflation of the lungs?
Barrel chest
A client presents to the emergency department with fluid overload. The nurse is concerned about fluid accumulation in the lungs. On which of the following areas would the nurse focus the lung assessment?
Bilateral lower lobes
If concern exists about fluid accumulation in a client's lungs, what area of the lungs will the nurse focus on during assessment?
Bilateral lower lobes
The nurse is caring for an adolescent client injured in a snowboarding accident. The client has a head injury, a fractured right rib, and various abrasions and contusions. The client has a blood pressure of 142/88 mm Hg, pulse of 102 beats/minute, and respirations of 26 breaths/minute. Which laboratory test best provides data on a potential impairment in ventilation?
Blood gases
A hospitalized client with terminal heart failure is nearing the end of life. The nurse observes which of the following breathing patterns?
Cheyne-Stokes breathing is characterized by a regular cycle where the rate and depth of breathing increase, then decrease until apnea occurs. The duration of apnea varies but progresses in length. This breathing pattern is associated with heart failure, damage to the respiratory center in the brain, or both.
What finding by the nurse may indicate that the patient has chronic hypoxia?
Clubbing of the fingers
The nurse auscultates crackles in a patient with a respiratory disorder. With what disorder would crackles be commonly heard?
Collapsed alveoli *Crackles are secondary to fluid in the airways or alveoli or to delayed opening of collapsed alveoli. Sibilant wheezes are associated with asthma and bronchospasm. Fine crackles are associated with pulmonary fibrosis.
A client appears to be breathing faster than during the last assessment. Which of the following interventions should the nurse perform?
Count the rate of respirations.
The nurse is assessing the lungs of a patient diagnosed with pulmonary edema. Which of the following would be expected upon auscultation?
Crackles at lung bases
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?
Cyanosis
Which of the following is a late sign of hypoxia?
Cyanosis
Which of the following ventilation-perfusion ratios is exhibited when a patient is diagnosed with pulmonary emboli?
Dead space
While conducting the physical examination during assessment of the respiratory system, which of the following conditions does a nurse assess by inspecting and palpating the trachea?
Deviation from the midline
The nurse enters the room of a client who is being monitored with pulse oximetry. Which of the following factors may alter the oximetry results?
Diagnosis of peripheral vascular disease
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.
Diaphragm contracts and elongates the chest cavity.
Which of the following clinical manifestations should a nurse monitor for during a pulmonary angiography, which indicates an allergic reaction to the contrast medium?
Difficulty in breathing
A nurse is preparing a client for bronchoscopy. Which instruction should the nurse give to the client?
Don't eat.
A client arrives at the physician's office stating dyspnea; a productive cough for thick, green sputum; respirations of 28 breaths/minute, and a temperature of 102.8° F. The nurse auscultates the lung fields, which reveal poor air exchange in the right middle lobe. The nurse suspects a right middle lobe pneumonia. To be consistent with this anticipated diagnosis, which sound, heard over the chest wall when percussing, is anticipated?
Dull
A client arrives at the physician's office stating dyspnea; a productive cough for thick, green sputum; respirations of 28 breaths/minute, and a temperature of 102.8° F. The nurse auscultates the lung fields, which reveal poor air exchange in the right middle lobe. The nurse suspects a right middle lobe pneumonia. To be consistent with this anticipated diagnosis, which sound, heard over the chest wall when percussing, is anticipated?
Dull Explanation: A dull percussed sound, heard over the chest wall, is indicative of little or no air movement in that area of the lung. Lung consolidation such as in pneumonia or fluid accumulation produces the dull sound. A tympanic sound is a high-pitched sound commonly heard over the stomach or bowel. A resonant sound is noted over normal lung tissue. A hyper resonant sound is an abnormal lower pitched sound that occurs when free air exists in disease processes such as pneumothorax.
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:
Emphysema
High or increased compliance occurs in which of the following conditions?
Emphysema *High or increased compliance occurs if the lungs have lost their elasticity and the thorax is over-distended as in emphysema. Conditions associated with decreased compliance include pneumothorax, pleural effusion, and ARDS.
A patient with sinus congestion points to a location on the inside of his eye as the area of pain. The nurse documents that the patient is complaining of pain in which sinus?
Ethmoid
A 6-month-old male client and his elder brother, a 3-year-old male, are being seen in the pediatric clinic for their third middle ear infection of the winter. The mother reports they develop an upper respiratory infection and an ear infection seems quick to follow. What contributes to this event?
Eustachian tubes *The nasopharynx contains the adenoids and openings of the eustachian tubes. The eustachian tubes connect the pharynx to the middle ear and are the means by which upper respiratory infections spread to the middle ear. The client's infection is not caused by genetics. The oropharynx contains the tongue. The epiglottis closes during swallowing and relaxes during respiration.
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?
Frontal
A nurse is receiving change-of-shift report about an older adult patient who has a diagnosis of chronic obstructive pulmonary disease (COPD). The nurse's colleague reports that she has applied oxygen at 6 L/min by nasal prongs in an effort to bring the patient's oxygen saturation levels above 92%. How should the nurse best interpret this colleague's action?
Giving oxygen at a high rate has the potential to interfere with the patient's hypoxic drive. Explanation: If oxygen is administered at a high enough rate to raise the PaO2 to normal in a patient with COPD, there is a risk of obliterating the hypoxic drive. Thus, low-flow oxygen is administered to a patient with COPD, while the nurse carefully assesses for complications. The use of a face mask does not mitigate this risk, and there is no 2- or 3-hour lag between oxygen administration and changes in oxygen saturation levels.
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?
How these issues affect the client's quality of life
A patient is seen in the emergency room for a severe case of diabetic acidosis. The respiratory note indicates the presence of Kussmaul's respirations. The nurse knows that this diagnosis is associated with which of the following?
Hyperventilation
A nurse is concerned that a client may develop postoperative atelectasis. Which nursing diagnosis would be most appropriate if this complication occurs?
Impaired gas exchange
The nursing instructor is talking with senior nursing students about diagnostic procedures used in respiratory diseases. The instructor discusses thoracentesis, defining it as a procedure performed for diagnostic purposes or to aspirate accumulated excess fluid or air from the pleural space. What would the instructor tell the students purulent fluid indicates?
Infection
You are a nurse in the radiology unit of your hospital. You are caring for a client who is scheduled for a lung scan. You know that lung scans need the use of radioisotopes and a scanning machine. Before the perfusion scan, what must the client be assessed for?
Iodine allergy
A patient diagnosed with diabetic ketoacidosis would be expected to have which type of respiratory pattern?
Kussmaul respirations *Kussmaul respirations are seen in patients with diabetic ketoacidosis. In Cheyne-Stokes respiration, rate and depth increase, then decrease until apnea occurs. Biot's respiration is characterized by periods of normal breathing (3 to 4 breaths) followed by a varying period of apnea (usually 10 to 60 seconds).
During a pulmonary assessment, the nurse observes the chest for configuration. She identifies the findings as normal. Which of the following would be consistent with normal assessment?
Lateral diameter greater than anteroposterior diameter
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?
Lungs are clear on auscultation.
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. Included in teaching would be which of the following regarding the MRI?
MRI can view soft tissues and can help stage cancers.
A thoracentesis is performed to obtain a sample of pleural fluid or a biopsy specimen from the pleural wall for diagnostic purposes. What does bloody fluid indicate?
Malignancy
Upon palpation of the sinus area, what would the nurse identify as a normal finding?
No sensation during palpation
The student nurse is learning breath sounds while listening to a client in the physician's office. An experienced nurse is assisting and notes air movement over the trachea to the upper lungs. The air movement is noted equally on inspiration as expiration. Which breath sounds would the nurse document?
Normal bronchovesicular sounds
A nurse practitioner diagnosed a patient with an infection in the maxillary sinuses. Select the area that the nurse palpated to make that diagnosis.
On the cheeks below the eyes
When assessing a client, which adaptation indicates the presence of respiratory distress?
Orthopnea
The nurse is performing an assessment for a patient with congestive heart failure. The nurse asks if the patient has difficulty breathing in any position other than upright. What is the nurse referring to?
Orthopnea *Orthopnea (inability to breathe easily except in an upright position) may be found in patients with heart disease and occasionally in patients with chronic obstructive pulmonary disease (COPD). Dyspnea (subjective feeling of difficult or labored breathing, breathlessness, shortness of breath) is a multidimensional symptom common to many pulmonary and cardiac disorders, particularly when there is decreased lung compliance or increased airway resistance. Tachypnea is abnormally rapid respirations. Bradypnea is abnormally slow respirations.
A client is receiving moderate sedation while undergoing bronchoscopy. Which assessment finding should the nurse attend to immediately?
Oxygen saturation of 90%
Which diagnostic imaging modality is more accurate than computed tomography in detecting malignancies?
PET Explanation: PET is more accurate in detecting malignancies than CT, and it has equivalent accuracy in detecting malignant nodules when compared with invasive procedures such as thorascopy. A gallium scan is used to stage bronchogenic cancer and document tumor regression after chemotherapy or radiation. MRI is used to characterize pulmonary nodules, to help stage bronchogenic carcinoma, and to evaluate inflammatory activity in interstitial lung disease. Pulmonary angiography is used to investigate thromboembolic disease of the lungs.
A patient comes to the emergency department complaining of a knifelike pain when taking a deep breath. What does this type of pain likely indicate to the nurse?
Pleurisy
During a preadmission assessment, the nurse finds increased tactile fremitus. She knows this sign is consistent with which of the following diagnoses?
Pneumonia
The nurse is caring for a client whose respiratory status has declined since shift report. The client has tachypnea, is restless, and displays cyanosis. Which diagnostic test should be assessed first?
Pulse oximetry
A nurse is reviewing arterial blood gas results on an assigned client. The pH is 7.32 with PCO2 of 49 mm Hg and a HCO3−of 28 mEq/L. The nurse reports to the physician which finding?
Respiratory acidosis
The nurse is caring for a client with chronic obstructive pulmonary disease. The client calls the doctor and states having difficulty breathing and overall feeling fatigued. The nurse realizes that this client is at high risk for which condition?
Respiratory acidosis
Your client has just had an invasive procedure to assess the respiratory system. What do you know should be assessed on this client?
Respiratory distress
A nurse is caring for a client after a lung biopsy. Which assessment finding requires immediate intervention?
Respiratory rate of 44 breaths/minute
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?
Rhonchi
Which ventilation-perfusion ratio is exhibited by acute respiratory distress syndrome (ARDS)?
Silent unit
In which position should the patient be placed for a thoracentesis?
Sitting on the edge of the bed
The nurse is caring for a patient who is to undergo a thoracentesis. In preparation for the procedure, the nurse will position the patient in which of the following positions?
Sitting on the edge of the bed
The nurse is admitting a client who just had a bronchoscopy. Which assessment should be the nurse's priority?
Swallow reflex
The nurse receives an order to obtain a sputum sample from a client with hemoptysis. When advising the client of the physician's order, the client states not being able to produce sputum. Which suggestion, offered by the nurse, is helpful in producing the sputum sample?
Take deep breaths and cough forcefully.
The nurse answers the call light of a male patient. The patient is complaining of an irritating tickling sensation in the throat, a salty taste, and a burning sensation in the chest. Upon further assessment, the nurse notes a tissue with bright red, frothy blood at the bedside. The nurse can assume the source of the blood is likely from which of the following?
The lungs
The body of a critically ill client may use which of the following homeostatic mechanisms to maintain normal pH?
The lungs eliminate carbonic acid by blowing off more CO2. *To maintain normal pH in critically ill clients, the lungs eliminate carbonic acid by blowing off more CO2. To maintain normal pH in critically ill clients, the lungs conserve CO2 by slowing respiratory volume. This is the way the body would compensate during an acid-base imbalance in cases of metabolic alkalosis. This is the way the body would compensate during an acid-base imbalance in cases of metabolic acidosis.
The nurse documents breath sounds that are soft, with inspiratory sounds longer than expiratory and found over the periphery of the lungs. Which of the following will the nurse chart?
Vesicular
The client is returning from the operating room following a broncho scopy. Which action, performed by the nursing assistant, would the nurse stop if began prior to nursing assessment?
The nursing assistant is pouring a glass of water to wet the client's mouth.
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?
The patient is in bronchospasm. Explanation: Wheezing is a high-pitched, musical sound heard mainly on expiration (asthma) or inspiration (bronchitis). It is often the major finding in a patient with bronchoconstriction or airway narrowing. Dyspnea (shortness of breath) and wheezing are generally associated with marked bronchospasm. Wheezing is not indicative of pneumonia or hemothorax. Wheezing does not indicate the need for physiotherapy
A client experiences a head injury in a motor vehicle accident. The client's level of consciousness is declining, and respirations have become slow and shallow. When monitoring a client's respiratory status, which area of the brain would the nurse realize is responsible for the rate and depth?
The pons *The pons in the brainstem controls rate and depth of respirations. When injury occurs or increased intracranial pressure results, respirations are slowed. The frontal lobe completes executive functions and cognition. The central sulcus is a fold in the cerebral cortex called the central fissure. The Wernicke's area is the area linked to speech.
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:
The saturation of hemoglobin by oxygen molecules
An 18-year-old male client is described as having pectus carinatum. The nurse is aware that the manifestation of this condition would be:
The sternum protrudes and the ribs are sloped backward.
The nurse is caring for a client diagnosed with asthma. While performing the shift assessment, the nurse auscultates breath sounds including sibilant wheezes, which are continuous musical sounds. What characteristics describe sibilant wheezes?
They can be heard during inspiration and expiration.
The volume of air inhaled and exhaled with each breath is termed which of the following?
Tidal volume
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?
To exchange oxygen and CO2 between the atmospheric air and the blood and between the blood and the cells
Knowing respiratory physiology is important to understand how the disease process can work within that system. Which hollow tube transports air from the laryngeal pharynx to the bronchi?
Trachea
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?
Turn the patient on his or her side to assess all lung fields, so that dependent areas can be assessed for breath sounds. Explanation: Assessment of the anterior and posterior lung fields is part of the nurse's routine evaluation. If the patient is supine, it would be essential to turn the patient to assess all lung fields, so that dependent areas can be assessed for breath sounds, including the presence of normal breath sounds and adventitious sounds. Failure to examine the dependent areas of the lungs can result in missing significant findings.
Which of the following alveolar cells secrete surfactant?
Type II *Type II alveolar cells are metabolically active and secrete surfactant, a phospholipid that decrease the surface tension in the alveoli and prevents their collapse. Type I alveolar cells are epithelial cells that form the alveolar walls. Type III alveolar cell macrophages are large phagocytic cells that ingest foreign matter and act as an important defense mechanism. Type IV is not a category of alveolar cells.
A 53-year-old male is a regular client in the respiratory group where you practice nursing. As with all adults, 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 the alveoli cells produce surfactant?
Type II cells
A nurse caring for a patient with a pulmonary embolism understands that a high ventilation-perfusion ratio may exist. What does this mean for the patient?
Ventilation exceeds perfusion.
You are caring for a 65-year-old client who has been newly diagnosed with emphysema. The client is confused by the new terms and wants to know what ventilation means. Which of the following can instruct this client?
Ventilation is breathing air in and out of the lungs.
The nursing instructor is teaching a pre-nursing pathophysiology class. The class is covering the respiratory system. The instructor explains that the respiratory system is comprised of both the upper and lower respiratory system. The nose is part of the upper respiratory system. The instructor continues to explain that the nasal cavities have a vascular and ciliated mucous lining. What is the purpose of the vascular and ciliated mucous lining of the nasal cavities?
Warm and humidify inspired air
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?
Wheezes
The nurse is performing chest auscultation for a patient with asthma. How does the nurse describe the high-pitched, sibilant, musical sounds that are heard?
Wheezes
While auscultating the lungs of a client with asthma, the nurse hears a continuous, high-pitched whistling sound on expiration. The nurse will document this sound as which of the following?
Wheezes *Wheezes, usually heard on expiration, are continuous, musical, high pitched, and whistle-like sounds caused by air passing through narrowed airways. Often, wheezes are associated with asthma.
A nurse is preparing a client with a pleural effusion for a thoracentesis. The nurse should:
assist the client to a sitting position on the edge of the bed, leaning over the bedside table.
A 68-year-old male patient has been admitted to the surgical unit from the PACU after surgical repair of an inguinal hernia. When performing the patient's admission assessment, the nurse notes that the patient has a barrel chest. This assessment finding should suggest to the nurse that the patient may have a history of what health problem?
emphysema
A nurse is teaching a client about a loss of lung compliance and the effect with ventilation. What client condition is the nurse teaching the client about?
emphysema Explanation: Emphysema, most commonly caused by smoking cigarettes, results in a loss of lung elasticity, which destroys the capillaries that supply the alveoli. Decreased compliance occurs if the lungs and the thorax are "stiff." Conditions associated with decreased compliance include morbid obesity, pneumothorax, hemothorax, pleural effusion, pulmonary edema, atelectasis, pulmonary fibrosis, and acute respiratory distress syndrome (ARDS). This causes airway collapse during expiration, dyspnea, and eventually cyanosis.
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:
mucous membranes. *Skin color doesn't affect the mucous membranes. Therefore, the nurse can assess for cyanosis by inspecting the client's mucous membranes. The lips, nail beds, and earlobes are less-reliable indicators of cyanosis because they're affected by skin color.
The nurse auscultates lung sounds that are harsh and cracking, sounding like two pieces of leather being rubbed together. The nurse would be correct in documenting this finding as
pleural friction rub. *A pleural friction rub is heard secondary to inflammation and loss of lubricating pleural fluid. Crackles are soft, high-pitched, discontinuous popping sounds that occur during inspiration. Sonorous wheezes are deep, low-pitched rumbling sounds heard primarily during expiration. Sibilant wheezes are continuous, musical, high-pitched, whistlelike sounds heard during inspiration and expiration.
Pink frothy sputum may be an indication of
pulmonary edema.
The term for the volume of air inhaled and exhaled with each breath is
tidal volume.
