course point ch. 20 assessment of pulmonary function

A resonant sound is noted over

NORMAL lung tissue

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? a. Lung infarction b. Bacterial pneumonia c. Bronchogenic carcinoma d. Pleurisy

Pleurisy Explanation: Pleuritic pain from irritation of the parietal pleura is sharp and seems to "catch" on inspiration; patients often describe it as being "like the stabbing of a knife."

Kyphoscoliosis is characterized by

elevation of the scapula and a corresponding S-shaped spine. This deformity limits lung expansion within the thorax. It may occur with osteoporosis and other skeletal disorders that affect the thorax.

With respect to respiration, diffusion is the

exchange of oxygen and CO2 through the alveolar-capillary membrane.

During a pulmonary angiography a contrast medium is injected into the

femoral artery

The crackling or grating sounds heard during inspiration or expiration are

friction rubs. ***They occur when the pleural surfaces are inflamed.***

Thoracentesis also may be used to

obtain a sample of pleural fluid or a biopsy specimen from the pleural wall for diagnostic purposes such as a culture, sensitivity, or microscopic examination.

A mechanical ventilator assists

patients to breathe who cannot do so on their own

The nurse assesses for anterior respiratory excursion by

placing the thumbs along the costal margin of the chest wall and instructing the client to inhale deeply

Egophony may occur in patients diagnosed with

pleural effusion.

Absent breath sounds occurs in

pneumothorax.

Crackles, formerly called rales, are

soft, high-pitched, discontinuous popping sounds that occur during inspiration (while usually heard on inspiration, they may also be heard on expiration); they may or may not be cleared by coughing.

A pigeon chest occurs as a result of

the anterior displacement of the sternum, which also increases the anteroposterior diameter. This may occur with rickets, Marfan syndrome, or severe kyphoscoliosis.

The amount of air inspired and expired with each breath is called: a. tidal volume. b. dead-space volume. c. vital capacity. d. residual volume.

tidal volume. Explanation: Tidal volume is the amount of air inspired and expired with each breath.

The presence of cyanosis is

-a very late indicator of hypoxia -from increased unoxygenated hemoglobin.

ABGs determine the blood's

-pH -oxygen-carrying capacity -levels of oxygen -CO2 -bicarbonate ion.

The nurse is caring for a client with recurrent hemoptysis who has undergone a bronchoscopy. Immediately following the procedure, the nurse should complete which action? a. Offer the client ice chips. b. Assess the client for a cough reflex. c. Ensure the client remains moderately sedated to decrease anxiety. d. Instruct the client that bed rest must be maintained for 2 hours.

Assess the client for a cough reflex. Explanation: After the procedure, the client must take nothing by mouth until the cough reflex returns, because the preoperative sedation and local anesthesia impair the protective laryngeal reflex and swallowing. Once the client demonstrates a cough reflex, the nurse may offer ice chips and eventually fluids. The client is sedated during the procedure, not afterward. The client is not required to maintain bed rest following the procedure.

The nurse is assessing the lungs of a patient diagnosed with pulmonary edema. Which of the following would be expected upon auscultation? a. Crackles at lung bases b. Bronchial breath sounds c. Absent breath sounds d. Egophony

Crackles at lung bases Explanation: A patient with pulmonary edema would be expected to have crackles in the lung bases, and possible wheezes.

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: a. Pulmonary edema b. Atelectasis c. Pleural effusion d. Emphysema

Emphysema Explanation: Emphysema, most commonly caused by smoking cigarettes, results in a loss of lung elasticity, which destroys the capillaries that supply the alveoli. This causes airway collapse during expiration, dyspnea, and eventually cyanosis.

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? a. Normal bronchial sounds b. Normal bronchovesicular sounds c. Abnormal vesicular sounds d. Abnormal bronchial sounds

Normal bronchovesicular sounds Explanation: Air movement over the trachea and upper lungs is a normal finding for broncho vesicular sounds. The air movement is noted equally on inspiration as expiration.

Serous fluid removed during thoracentesis may be associated with

cancer, inflammatory conditions, or heart failure.

The larynx, or voice box, is a

cartilaginous framework between the pharynx and trachea.

Bronchial breath sounds occur in

consolidation, such as pneumonia.

Barrel chest occurs as a result of

overinflation of the lungs, which increases the anteroposterior diameter of the thorax. It occurs with aging and is a hallmark sign of emphysema and COPD. ***In a patient with emphysema, the ribs are more widely spaced and the intercostal spaces tend to bulge on expiration.***

Funnel chest occurs when

there is a depression in the lower portion of the sternum. This may compress the heart and great vessels, resulting in murmurs. Funnel chest may occur with rickets or Marfan's syndrome.

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? a. Crackles b. Wheezes c. Rales d. Rhonchi

Wheezes Explanation: Sibilant wheezes are continuous, musical, high-pitched, whistlelike sounds heard during inspiration and expiration caused by air passing through narrowed or partially obstructed airways; they may clear with coughing.

Type I alveolar cells

line most alveolar surfaces.

Thoracentesis is performed with

local anesthesia.

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? a. Son's statement b. Crackles c. Respiratory rate d. Cyanosis

Cyanosis Explanation: The client's appearance may give clues to respiratory status. Cyanosis, a bluish coloring of the skin, is a very late indicator of hypoxia.

A nurse is preparing a client for bronchoscopy. Which instruction should the nurse give to the client? a. Don't eat. b. Don't walk. c. Don't cough. d. Don't talk.

Don't eat. Explanation: Bronchoscopy involves visualization of the trachea and bronchial tree. To prevent aspiration of stomach contents into the lungs, the nurse should instruct the client not to eat or drink anything for approximately 6 hours before the procedure.

A patient diagnosed with diabetic ketoacidosis would be expected to have which type of respiratory pattern? a. Cheyne-Stokes b. Apnea c. Kussmaul respirations d. Biot's respirations

Kussmaul respirations Explanation: Kussmaul respirations are seen in patients with diabetic ketoacidosis.

The trachea transports air from

the laryngeal pharynx to the bronchi and lungs.

Expiratory reserve volume is

the maximum volume of air that can be exhaled after a normal inhalation.

Preventing infection is the main function of

the tonsils and adenoids.

Cyanosis appears when

there is at least 5 g/dL of unoxygenated hemoglobin.

A client with chronic bronchitis is admitted with an exacerbation of symptoms. During the nursing assessment, the nurse will expect which of the following findings? Select all that apply. a. Use of accessory muscles to breathe b. Purulent sputum with frequent coughing c. Tympany percussed bilaterally over the lung bases d. Hypoventilatory breathing pattern e. Respiratory rate of 10 breaths per minute

-Use of accessory muscles to breathe -Purulent sputum with frequent coughing Explanation: Chronic bronchitis increases airway resistance and can thicken bronchial mucosa during an exacerbation. The client will have dyspnea requiring the use of accessory muscles to breathe, along with tachypnea and sputum production. Bronchial irritation and the need to expectorate mucus will lead to coughing. Percussion in this client would lead to resonant or hyperresonant sounds.

A nurse would question the accuracy of a pulse oximetry evaluation in which of the following conditions? a. A client experiencing hypothermia b. A client sitting in a chair after prolonged bed rest c. A client receiving oxygen therapy via Venturi mask d. A client on a ventilator with PEEP

A client experiencing hypothermia Explanation: SpO2 values obtained by pulse oximetry are unreliable in states of low perfusion such as hypothermia.

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? a. A puncture at the radial artery b. The pleural surfaces c. A catheter in the arm vein d. The trachea and bronchi

A puncture at the radial artery Explanation: Blood gas samples are obtained through an arterial puncture at the RADIAL, BRACHIAL, or FEMORAL ARTERY. ***A client also may have an indwelling arterial catheter from which arterial samples are obtained.***

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? a. Raised temperature in the affected limb b. Excessive capillary refill c. Flushed feeling in the client d. Absent distal pulses

Absent distal pulses Explanation: When monitoring clients after a pulmonary angiography, nurses must notify the physician about diminished or absent distal pulses, cool skin temperature in the affected limb, and poor capillary refill. When the contrast medium is infused, the client will sense a warm, flushed feeling.

A patient visited a health care clinic for treatment of upper respiratory tract congestion, fatigue, and sputum production that was rust-colored. Which of the following diagnoses is likely based on this history and inspection of the sputum? a. Bronchiectasis b. Bronchitis c. A lung abscess d. An infection with pneumococcal pneumonia

An infection with pneumococcal pneumonia Explanation: Sputum that is rust colored suggests infection with pneumococcal pneumonia.

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

Asking the client to repeat "ninety-nine" as the nurse's hands move down the client's thorax Explanation: While the nurse is assessing for tactile fremitus, the client is asked to repeat "ninety-nine" or "one, two, three," or "eee, eee, eee" as the nurse's hands move down the client's thorax. Vibrations are detected with the palmar surfaces of the fingers and hands, or the ulnar aspect of the extended hands, on the thorax. The hand(s) are moved in sequence down the thorax, and corresponding areas of the thorax are compared.

What finding by the nurse may indicate that the patient has chronic hypoxia? a. Cyanosis b. Clubbing of the fingers c. Peripheral edema d. Crackles

Clubbing of the fingers Explanation: Clubbing of the fingers is a change in the normal nail bed. It appears as sponginess of the nail bed and loss of the nail bed angle. It is a sign of lung disease that is found in patients with chronic hypoxic conditions, chronic lung infections, or malignancies of the lung ***The other signs listed may represent only a temporary hypoxia.***

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? a. Rhonchi b. Crackles c. Bronchial d. Pleural friction rub

Rhonchi Explanation: Rhonchi are deep, low-pitched, rumbling sounds heard usually on expiration. The etiology of rhonchi is associated with chronic bronchitis.

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

Count the rate of respirations. Explanation: Observing the rate and depth of respiration is an important aspect of a nursing assessment. The normal adult resting respiratory rate is 12 to 18 breaths per minute. Tachypnea is rapid breathing with a rate greater than 24 breaths per minute.

The nurse is caring for a patient with a pulmonary disorder. What observation by the nurse is indicative of a very late symptom of hypoxia? a. Cyanosis b. Confusion c. Dyspnea d. Restlessness

Cyanosis Explanation: Cyanosis, a bluish coloring of the skin, is a very late indicator of hypoxia. The presence or absence of cyanosis is determined by the amount of unoxygenated hemoglobin in the blood.

What is the main function of the epiglottis?

to protect the lower airway

Sibilant wheezes result from

air passing through narrowed or partially obstructed air passages and are heard in clients with increased secretions.

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.

Bronchitis usually yields

a small amount of purulent sputum.

A tympanic sound is

a high-pitched sound commonly heard over the stomach or bowel.

Vital capacity is the

maximum amount of air that can be moved out of the lungs after maximal inspiration and expiration

Vital capacity refers to

the total volume of air that can be exhaled during a slow, maximal expiration after maximal inspiration.

Alternate positions in which the client could be placed for thoracentesis are:

1. straddling a chair with the arms and head resting on the back of the chair, or 2. lying on the unaffected side with the head of the bed elevated 30 to 45 degrees (if the client is unable to assume a sitting position).

The sinuses can be inspected by transillumination, where

a light is passed through the sinuses. If the light fails to penetrate, the cavity contains fluid.

What is the primary function of the larynx? a. preventing infection b. producing sound c. facilitating coughing d. protecting the lower airway from foreign objects

producing sound Explanation: Its primary function is to produce sound. While the larynx assists in protecting the lower airway, this is mainly the function of the epiglottis. ***Facilitating coughing is a secondary function of the larynx***.

Pulmonary perfusion refers to the

provision of blood supply to the lungs

Bronchiectasis and a lung abscess usually are associated with

purulent thick and yellow-green sputum

A client with exacerbation of chronic obstructive pulmonary disease (COPD) is scheduled for a thoracentesis. Which nursing intervention would be appropriate for client safety? a. Administering a prn cough suppressant b. Obtaining arterial blood gas values immediately after the procedure c. Assisting the client to a prone position d. Applying oxygen via nasal cannula

Administering a prn cough suppressant Explanation: Encourage the client to refrain from coughing. Any sudden and unexpected movement, such as coughing, can traumatize the visceral pleura and lung. Clients experiencing exacerbation of COPD often have a productive cough; therefore, administration of a prn cough medication would be helpful to suppress any potential coughing during the procedure.

If concern exists about fluid accumulation in a client's lungs, what area of the lungs will the nurse focus on during assessment? a. Anterior bronchioles b. Left lower lobe c. Posterior bronchioles d. Bilateral lower lobes

Bilateral lower lobes Explanation: Crackles are secondary to fluid in the alveoli and create a soft, discontinuous popping sound. Because fluid creates these adventitious sounds, the principle of gravity will remind the nurse to focus the assessment on the lower portion of the thorax or the lower lobes of the lungs.

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? a. Reduced lighting in the room b. Diagnosis of peripheral vascular disease c. Placement of the probe on an earlobe d. Increased temperature of the room

Diagnosis of peripheral vascular disease Explanation: Pulse oximetry is a noninvasive method of monitoring oxygen saturation of hemoglobin. A probe is placed on the fingertip, forehead, earlobe, or bridge of nose. Inaccuracy of results may be from anemia, bright lights, shivering, nail polish, or 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. a. Lungs are pulled up and pushed back against the thoracic cage. b. Intercostals muscles relax to allow for expansion. c. Anteroposterior rib diameter decreases. d. Diaphragm contracts and elongates the chest cavity.

Diaphragm contracts and elongates the chest cavity. Explanation: The diaphragm contracts during inspiration and pulls the lungs in a downward and forward direction. The abdomen appears to enlarge because the abdominal contents are being compressed by the diaphragm. With inspiration, the diaphragmatic pull elongates the chest cavity, and the external intercostal muscles (located between and along the lower borders of the ribs) contract to raise the ribs, which expands the anteroposterior diameter. The effect of these movements is to decrease the intrapulmonary pressure.

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? a. Dull b. Resonant c. Hyperresonant d. Tympanic

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 nurse is concerned that a client may develop postoperative atelectasis. Which nursing diagnosis would be most appropriate if this complication occurs? a. Ineffective airway clearance b. Impaired spontaneous ventilation c. Impaired gas exchange d. Decreased cardiac output

Impaired gas exchange Explanation: Airflow is decreased with atelectasis, which is a bronchial obstruction from collapsed lung tissue. If there is an obstruction, there is limited or no gas exchange in this area. Impaired gas exchange is thus the most likely nursing diagnosis with atelectasis.

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? a. Lung blood flow can be viewed after a radiopaque agent is injected. b. Tumor densities can be seen with radiolucent images. c. MRI can view soft tissues and can help stage cancers. d. Narrow-beam x-ray can scan successive lung layers.

MRI can view soft tissues and can help stage cancers. Explanation: MRI uses magnetic fields and radiofrequency signals to produce a detailed diagnostic image. MRI can visualize soft tissues, characterize nodules, and help stage carcinomas.

Upon palpation of the sinus area, what would the nurse identify as a normal finding? a. Light not going through the sinus cavity b. No sensation during palpation c. Pain sensation behind the eyes d. Tenderness during palpation

No sensation during palpation Explanation: Sinus assessment involves using the thumbs to apply gentle pressure in an upward fashion at the sinuses. Tenderness suggests inflammation.

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? a. Bradypnea b. Orthopnea c. Tachypnea d. Dyspnea

Orthopnea Explanation: 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).

When assessing a client, which adaptation indicates the presence of respiratory distress? a. Respiratory rate of 14 breaths per minute b. Productive cough c. Orthopnea d. Sore throat

Orthopnea Explanation: Orthopnea is the inability to breathe easily except when upright. This positioning can mean while in bed and propped with a pillow or sitting in a chair. If a client cannot breathe easily while lying down, there is an element of respiratory distress.

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? a. Arterial blood gases b. Pulse oximetry c. Pulmonary function test d. Chest x-ray

Pulse oximetry Explanation: Pulse oximetry is a noninvasive method to determine arterial oxygen saturation. Normal values are 95% and above. Using this diagnostic test first provides rapid information of the client's respiratory system.

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

Swallow reflex Explanation: The physician sprays a local anesthetic into the client's throat before performing a bronchoscopy. The nurse must assess the swallow reflex when the client returns to the unit and before giving him anything by mouth. The nurse should also assess for medication allergies, carotid pulse, and deep breathing, but they aren't the priority at this time.

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? a. Drink 8 oz of water to thin the secretions for expectoration. b. Take deep breaths and cough forcefully. c. Use the secretions present in the oral cavity. d. Tickle the back of the throat to produce the gag reflex.

Take deep breaths and cough forcefully. Explanation: Taking deep breaths moves air around the sputum and coughing forcefully moves the sputum up the respiratory tract. Once in the pharynx, the sputum can be expectorated into a specimen container. ***Dilute and thinned secretions are not helpful in aiding expectoration***

The client is returning from the operating room following a bronchoscopy. Which action, performed by the nursing assistant, would the nurse stop if began prior to nursing assessment? a. The nursing assistant is assisting the client to a semi-Fowler's position. b. The nursing assistant is asking a question requiring a verbal response. c. The nursing assistant is pouring a glass of water to wet the client's mouth. d. The nursing assistant is assisting the client to the side of the bed to use a urinal.

The nursing assistant is pouring a glass of water to wet the client's mouth. Explanation: When completing a procedure which sends a scope down the throat, the gag reflex is anesthetized to reduce discomfort. Upon returning to the nursing unit, the gag reflex must be assessed before providing any food or fluids to the client. The client may need assistance following the procedure for activity and ambulation but this is not restricted in the post procedure period.

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? a. Wernicke's area b. Central sulcus c. The pons d. The frontal lobe

The pons Explanation: 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.

Perfusion refers to blood supply to the lungs, through which the lungs receive nutrients and oxygen. What are the two methods of perfusion? a. The two methods of perfusion are the bronchial and alveolar circulation. b. The two methods of perfusion are the bronchial and pulmonary circulation. c. The two methods of perfusion are the bronchial and capillary circulation. d. The two methods of perfusion are the alveolar and pulmonary circulation.

The two methods of perfusion are the bronchial and pulmonary circulation. Explanation: The two methods of perfusion are the bronchial and pulmonary circulation. There is no alveolar circulation. Capillaries are the vessels that performs the perfusion regardless of which area of the lung they are in.

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? a. They can be heard during inspiration and expiration. b. They result from air passing through widened air passages. c. They are heard in clients with decreased secretions. d. They occur when the pleural surfaces are inflamed.

They can be heard during inspiration and expiration. Explanation: Sibilant or hissing or whistling wheezes are continuous musical sounds that can be heard during inspiration and expiration.

A client with a suspected pulmonary disorder undergoes pulmonary function tests. To interpret test results accurately, the nurse must be familiar with the terminology used to describe pulmonary functions. Which term refers to the volume of air inhaled or exhaled during each respiratory cycle? a. Vital capacity b. Tidal volume c. Functional residual capacity d. Maximal voluntary ventilation

Tidal volume Explanation: Tidal volume refers to the volume of air inhaled or exhaled during each respiratory cycle when breathing normally. Normal tidal volume ranges from 400 to 700 ml.

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? a. To move CO2 out of the atmospheric air and into the expired air b. To exchange atmospheric air between the blood and the cells c. To exchange oxygen and CO2 between the atmospheric air and the blood and between the blood and the cells d. To move O2 out of the atmospheric air and into the retained air

To exchange oxygen and CO2 between the atmospheric air and the blood and between the blood and the cells Explanation: The main function of the respiratory system is to exchange oxygen and CO2 between the atmospheric air and the blood and between the blood and the cells. This process is called respiration. The purpose of respiration is not to move any gas into the expired air; retained air is simply a distractor for this question; and atmospheric air is not exchanged between the blood and the cells.

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

Use of accessory muscles Explanation: The use of accessory muscles for respiration indicates the client is having difficulty breathing.

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? a. Tracheal b. Adventitious c. Bronchial d. Vesicular

Vesicular Explanation: Vesicular breath sounds are heard over the entire lung field except the upper sternum and between the scapulae. Their pitch and intensity are low. Inspiration sounds are longer than expiratory sounds. These are considered normal breath sounds.

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? a. Warm and humidify inspired air b. Cool and dry expired air c. Moisten and filter expired air d. Move mucus to the back of the throat

Warm and humidify inspired air Explanation: The vascular and ciliated mucous lining of the nasal cavities warms and humidifies inspired air. It is the function of the cilia alone to move mucus in the nasal cavities and filter the inspired air.

The pharynx, or throat, carries

air from the nose to the larynx and food from the mouth to the esophagus.

Residual volume is the

amount of air remaining in the lungs after forcibly exhaling.

Dead-space volume is the

amount of air remaining in the upper airways that never reaches the alveoli.

A hyper resonant sound is

an abnormal lower pitched sound that occurs when free air exists in disease processes such as pneumothorax.

A nurse is preparing a client with a pleural effusion for a thoracentesis. The nurse should: a. raise the arm on the side of the client's body on which the physician will perform the thoracentesis. b. assist the client to a sitting position on the edge of the bed, leaning over the bedside table. c. raise the head of the bed to a high Fowler's position. d. place the client supine in the bed, which is flat.

assist the client to a sitting position on the edge of the bed, leaning over the bedside table. Explanation: A physician usually performs a thoracentesis when the client is sitting in a chair or on the edge of the bed, with the legs supported and the arms folded and resting on a pillow or on the bedside table.

The nurse is instructing the patient on the collection of a sputum specimen. What should be included in the instructions? (Select all that apply.) a. Rinse with mouthwash prior to providing the specimen. b. Initially, clear the nose and throat. c. Take a few deep breaths before coughing. d. Use diaphragmatic contractions to aid in the expulsion of sputum. e. Spit surface mucus and saliva into a sterile specimen container.

b. Initially, clear the nose and throat. c. Take a few deep breaths before coughing. d. Use diaphragmatic contractions to aid in the expulsion of sputum.

A client has suspected fluid accumulation in the pleural space of the lungs and is scheduled for a thoracentesis. The nurse will implement which of the following for this procedure? Select all that apply. a. Place the client in the prone position. b. Apply pressure to the puncture site after the procedure. c. Educate the client about the need to cleanse the thoracic area. d. Prepare the client for magnetic resonance imaging after the procedure to verify tube placement. e. Complete a respiratory assessment after the procedure.

c. Educate the client about the need to cleanse the thoracic area. b. Apply pressure to the puncture site after the procedure. e. Complete a respiratory assessment after the procedure. Explanation: A thoracentesis is performed to aspirate fluid or air from the pleural space. The nurse assists the client to a sitting or side-lying position, which provides support and exposes the base of the thorax. Encouraging a position of comfort helps the client to relax for the procedure. The nurse prepares the client by explaining the steps of the procedure and begins by cleansing the thoracic area using aseptic technique. After the procedure, the nurse applies pressure to the site to help stop bleeding; then, he or she applies an air-tight, sterile dressing. A chest x-ray verifies that there is no pneumonthorax. The nurse will monitor at intervals the client's respiratory function.

Diaphragmatic and pursed-lip breathing are two

controlled breathing techniques that help the client conserve energy.

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? a. Heart failure b. Cancer c. Inflammation d. Infection

d. infection

Rhonchi, or sonorous wheezes, are

deep, low-pitched rumbling sounds heard primarily during expiration; they are caused by air moving through narrowed tracheobronchial passages.

Type III alveolar cells

destroy foreign material, such as bacteria.

In lung carcinoma, the pain may be

dull and persistent because the cancer has invaded the chest wall, mediastinum, or spine.

Maximal voluntary ventilation is the

greatest volume of air expired in 1 minute with maximal voluntary effort.

Clients with orthopnea are placed in a

high Fowler's position to facilitate breathing

In pathologic conditions, dead space may also exist

in the lower airways.

The nurse assesses for diaphragmatic excursion by

instructing the client to take a deep breath and hold it while the diaphragm is percussed.

A client has been newly diagnosed with emphysema. The nurse should explain to the client that by definition, ventilation: a. is when the body changes oxygen into CO2. b. provides a blood supply to the lungs. c. is breathing air in and out of the lungs. d. helps people who cannot breathe on their own.

is breathing air in and out of the lungs. Explanation: Ventilation is the actual movement of air in and out of the respiratory tract.

The nurse answers a client's call light. The client reports 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 the a. stomach. b. lungs. c. nose. d. rectum.

lungs. Explanation: Blood from the lung is usually bright red, frothy, and mixed with sputum. Initial symptoms include a tickling sensation in the throat, a salty taste, a burning or bubbling sensation in the chest, and perhaps chest pain, in which case the client tends to splint the bleeding side. This blood has an alkaline pH (>7.0).

A small amount of fluid lies between the visceral and parietal pleurae. When excess fluid or air accumulates, the physician

performs thoracentesis by aspirating the fluid from the pleural space by inserting a needle into the chest wall.

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).

What occurs with Cheyne-Stokes respiration?

rate and depth increase, then decrease until apnea occurs

A thoracentesis is performed to

remove fluid and air from the pleural cavity and to aspirate pleural fluid for analysis, pleural biospy, or instillation of medication into the pleural space.

The bronchioles are

smaller subdivisions of bronchi within the lungs

Functional residual capacity refers to

the volume of air remaining in the lungs after a normal expiration.

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? a. type III cells b. type I cells c. type II cells d. type IV cells

type II cells Explanation: Type II cells produce surfactant, a phospholipid that alters the surface tension of alveoli, preventing their collapse during expiration and limiting their expansion during inspiration.