Honan - Respiratory Function

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?

"I will breathe in through my mouth and out through my nose."

A nurse is instructing the client on the normal sensations that can occur when contrast medium is infused during pulmonary angiography. Which client statement demonstrates an understanding of the teaching?

"I will feel warm and may have chest pain"

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."

A nurse would question the accuracy of a pulse oximetry evaluation in which of the following conditions?

A client experiencing 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 puncture at the radial artery

Which is a true statement regarding air pressure variances?

Air is drawn through the trachea and bronchi into the alveoli during inspiration.

The nurse is caring for a client diagnosed with pneumonia. The nurse assesses the client for tactile fremitus by completing which action?

Asking the client to repeat "ninety-nine" as the nurse's hands move down the client's thorax

The nurse is caring for a client reporting chest discomfort. The client's diagnosis at admission is left lower lobe pneumonia. Which strategy will the nurse instruct the client to use to help alleviate the discomfort?

Assume a left-side lying position while in bed

The nurse is assessing a patient in respiratory failure. What finding is a late indicator of hypoxia?

Cyanosis

What happens to the diaphragm during inspiration?

It contracts and flattens

The nurse is caring for a client in the immediate post-thoracentesis period. In which position is the client placed?

Lying on the unaffected side

The clinical finding of pink, frothy sputum may be an indication of which condition?

Pulmonary edema

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 the nurse perform first?

Pulse oximetery

The nurse is studying for a physiology test over the respiratory system. What should the nurse know about central chemoreceptors in the medulla?

They respond to changes in CO2 levels and hydrogen ion concentrations (pH) in the cerebrospinal fluid.

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

A nurse working in the radiology clinic is assisting with a client after an unusual arterial procedure. What assessment should the nurse notify the health care provider about?

absent distal pulses

The volume of air inhaled and exhaled with each breath is termed

tidal volume

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%

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?

A patient who has crackles on auscultation

The nurse is caring for a patient admitted with chronic obstructive pulmonary disease. During assessment, the nurse finds that the patient is experiencing a change in his respiratory and mental status. The nurse is aware that the most accurate measurement of the concentration of oxygen in the patient's blood is what?

An arterial blood gas (ABG) study

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

An infection with pneumococcal pneumonia

The nurse is completing a physical assessment of an older adult's respiratory system. Which finding(s) indicate to the nurse that the client is experiencing an age-related change to the chest wall and respiratory muscles? Select all that apply.

Kyphosis Barrel chest Shortness of breath Abdominal breathing Reduced cough reflex

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.

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?

PaCO2

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

What is the primary function of the larynx?

Producing sound

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 pt on their side to assess all lung fields, so that dependent areas can be assessed for breath sounds

A nurse is assessing a client's respiratory system. Which alveolar cells secrete surfactant to reduce lung surface tension?

Type II

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?

assess the client for a cough reflex

A nurse is examining a client's chest. During the exam, the nurse palpates what feels like bubbles under the client's chest muscles. Which term would the nurse use when documenting this finding?

crepitus

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 breathing

As a component of a patient's comprehensive respiratory assessment, the nurse is preparing to assess for the presence of tactile fremitus. How should the nurse direct the patient prior to this assessment?

id like you to say 'one, two, three' for me a few times while i feel your chest and back

A client is diagnosed with pneumonia. Which finding would the nurse expect to assess in this client? Select all that apply.

increased tactile fremitus bronchophony

A client has been newly diagnosed with emphysema. The nurse should explain to the client that by definition, ventilation:

is breathing air in and out of the lungs

A client has just undergone bronchoscopy. Which nursing assessment is most important at this time?

level of conciousness

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.

When assessing a client, which adaptation indicates the presence of respiratory distress?

orthopnea

In which position should the client be placed for a thoracentesis?

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 nursing instructor is teaching students about the respiratory system. The instructor knows the teaching has been effective when a student makes which statement?

ventilation is the movement of air in and out of the respiratory tract

A client appears to be breathing faster than during the last assessment. Which of the following actions should the nurse perform?

Count the rate of respirations.

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.

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 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

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?

Emphysema

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 client with chronic bronchitis is admitted to the health facility. Auscultation of the lungs reveals low-pitched, rumbling sounds. What breath sound should the nurse document?

Rhonchi

A client with chronic bronchitis is admitted to the health facility. Auscultation of the lungs reveals low-pitched, rumbling sounds. Which term should the nurse document?

Rhonchi

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?

The client has a funnel chest.

A nurse is caring for a client who has frequent upper respiratory infections. Which structure is most helpful in protecting against infection?

Tonsils

What finding by the nurse may indicate that the client has chronic hypoxia?

clubbing of the fingers

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

Which hollow tube transports air from the laryngeal pharynx to the bronchi?

trachea

What is the difference between respiration and ventilation?

ventilation is the movement of air in and out of the resp tract

The nurse inspects the thorax of a patient with advanced emphysema. The nurse expects chest configuration changes consistent with a deformity known as:

Barrel chest

What would the instructor tell the students purulent fluid indicates?

Infection

A new nurse auscultates adventitious breath sounds but is not sure what to document and confers with an experienced nurse. This experienced nurse documents a pleural friction rub. Which of the following did the experienced nurse do during her assessment to identify the rub?

Instructed the client to hold the breath

The nurse is in the radiology unit of the hospital. The nurse is caring for a client who is scheduled for a lung scan. The nurse knows 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

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 is assessing the lungs of a patient diagnosed with pulmonary edema. Which of the following would be expected upon auscultation?

Crackles at lung bases