M6 - Gas Exchange & Lung/Resp Assessment

The nurse percusses a patient's chest and feels dullness. The nurse suspects which diagnosis? 1. Pneumonia 2. Chronic obstructive pulmonary disease (COPD) 3. Bronchiectasis 4. Emphysema

1. Pneumonia

On auscultation of a patient's lungs, the nurse hears a low-pitched, coarse, loud, and low snoring sound. Which term does the nurse use to document this finding? 1. Rhonchi 2. Wheeze 3. Crackles 4. Pleural friction rub

1. Rhonchi

A pregnant client is admitted to the high-risk unit with abdominal pain and heavy vaginal bleeding. Which is the nurse's priority intervention? 1. Starting oxygen therapy 2. Administering an opioid 3. Elevating the head of the bed 4. Drawing blood for laboratory tests

1. Starting oxygen therapy

Which breath sounds are expected over the posterior chest of an adult? 1. Vesicular 2. Bronchovesicular 3. Bronchial 4. Bronchoalveolar

1. Vesicular

During the problem-based history, a patient reports coughing up sputum when lying on the right side, but not when lying on the back or left side. The nurse suspects this patient may have a lung abscess. What additional question does the nurse ask to gather more data? Correct! 1. "Does the sputum have an odor?" 2. "Do you have chest pain when you take a deep breath?" 3. "Have you also experienced tightness in your chest?" 4. "Have you coughed up any blood?"

1. "Does the sputum have an odor?"

The nurse is administering high concentrations of oxygen (O 2) to a child. Which is the nurse's most important consideration concerning the O 2? 1. A nonrebreather mask should be used. 2. The tank should be labeled flammable. 3. 2 must be warmed before administration. 4. 2 must be humidified before administration.

1. 2 must be humidified before administration. --> O2 Should be humidified due to drying nature

The nurse is caring for a 75-year-old client who had radical head and neck surgery. Thirty minutes after awakening from anesthesia, the client becomes agitated, disoriented, and confused. Which action would the nurse take? 1. Administer the prescribed oxygen. 2. Administer the prescribed antianxiety medication. 3. Notify the health care provider immediately of the findings. 4. Record the observations and continue to observe the client

1. Administer the prescribed oxygen.

A nurse is assessing the respiratory system of a healthy adult. Which findings does this nurse expect to find? Select all that apply. 1. Anteroposterior diameter of the chest about a 1:2 ratio of anteroposterior to lateral diameter 2. Bronchophony revealing clear voice sounds 3. Respiratory rate of 24 breaths/min 4. Symmetric thorax with ribs sloping downward at about 45 degrees relative to the spine 5. Thoracic expansion that is symmetric bilaterally 6. Breath sounds clear with vesicular breath sounds heard over most lung fields

1. Anteroposterior diameter of the chest about a 1:2 ratio of anteroposterior to lateral diameter 4. Symmetric thorax with ribs sloping downward at about 45 degrees relative to the spine 5. Thoracic expansion that is symmetric bilaterally 6. Breath sounds clear with vesicular breath sounds heard over most lung fields

Which action would be the nurse's first priority when receiving a client with major burns? 1. Assessing airway patency 2. Checking the client from head to toe 3. Administering oxygen as needed 4. Elevating the extremities if no fractures are noticed

1. Assessing airway patency

During a symptom analysis, a patient describes his productive cough and states his sputum is thick and yellow. Based on these data, the nurse suspects which factor as the cause of these symptoms? 1. Bacteria 2. Fungus 3. Virus 4. Allergy

1. Bacteria

On inspection, the nurse finds the patient's anteroposterior diameter of the chest to be the same as the lateral diameter. What other findings does this nurse expect during the examination? Select all that apply. 1. Decreased breath sounds heard on auscultation 2. Hyperresonance heard on percussion 3. A sharp, abrupt pain reported when the patient breathes deeply 4. Inspiratory wheezing found on auscultation 5. Deceased diaphragmatic excursion on percussion 6. Decreased to absent vibration on vocal fremitus

1. Decreased breath sounds heard on auscultation 2. Hyperresonance heard on percussion 5. Deceased diaphragmatic excursion on percussion 6. Decreased to absent vibration on vocal fremitus

A nurse hears inspiratory and expiratory wheezes bilaterally. What is the meaning of this finding? 1. Narrowed airways 2. Fluid in the alveoli 3. Consolidation in alveoli 4. Sputum in the bronchi

1. Narrowed airways --> Air moving within narrowed bronchi creates the wheezing sound. Consolidation would cause decreased or absent breath sounds. Sputum causes rhonchi. Fluid in the alveoli causes crackles.

What are the functions of the upper airways? Select all that apply. 1. Warm, humidify, and filter air entering lungs. 2. Prevent foreign matter from entering respiratory system. 3. Conduct air to lower airway. 4. Provide transportation of oxygen and carbon dioxide between alveoli and cells. 5. Provide area for gas exchange.

1. Warm, humidify, and filter air entering lungs. 2. Prevent foreign matter from entering respiratory system. 3. Conduct air to lower airway.

Narrowing of the bronchi creates which adventitious sound? 1. Wheeze 2. Crackles 3. Rhonchi 4. Pleural friction rub

1. Wheeze

A nurse hears bronchovesicular sounds in the posterior chest on either side of the spine. This finding indicates: 1. a normal finding. 2. pleural effusion. 3. lung cancer. 4. pneumonia.

1. a normal finding. --> Bronchovesicular sounds are expected in this area of the chest. Pneumonia would cause crackles or no breathing sounds if there were consolidation. Lung cancer usually is not detected by auscultation. No breath sounds would be heard over a pleural effusion.

A patient complains to the nurse of coughing up green phlegm and is having difficulty breathing at rest. The nurse suspects: 1. bacterial pneumonia. 2. a viral infection. 3. tuberculosis. 4. pulmonary edema.

1. bacterial pneumonia. --> The sputum by bacterial pneumonia also will have a foul smell. Viral infections usually are associated with the production of white or clear mucus. Sputum production with tuberculosis tends to be a rust color. Pink frothy sputum is a classic finding in patients with pulmonary edema

The nurse assesses the lungs of a client and auscultates soft, crackling, bubbling breath sounds that are more obvious on inspiration. Which would the nurse document these sounds as? 1. Vesicular 2. Bronchial 3. Crackles 4. Rhonchi

3. Crackles

A patient tells the nurse that he has smoked 1½ packs of cigarettes a day for 14 years. The nurse records this as _____ pack-years? 1. 14 2. 21 3. 28 4. 35

2. 21

A patient tells the nurse that she has smoked two packs of cigarettes a day for 20 years. The nurse records this as how many pack-years? 1. 20 2. 40 3. 10 4. 60

2. 40

After taking a brief health history, a nurse needs to complete a focused respiratory assessment on which patient? 1. A female who has a history of gout 2. A male who works as a painter 3. A male who plays basketball and hockey 4. A female who recently moved into a college dormitory

2. A male who works as a painter

A nurse is auscultating the lungs of a healthy female patient and hears crackles on inspiration. What action can the nurse take to ensure this is an accurate finding? 1. Make sure the bell of the stethoscope is used rather than the diaphragm. 2. Ask the patient to cough then repeat the auscultation. 3. Ask the patient not to talk while the nurse is listening to the lungs. 4. Change the patient's position.

2. Ask the patient to cough then repeat the auscultation.

The nurse is palpating a patient's chest wall. What can be accomplished with palpation of the chest? 1. Identification of lung sounds 2. Assessment of equal chest expansion 3. Approximation of lung size 4. Determination of oxygenation

2. Assessment of equal chest expansion

The nurse auscultates prolonged expiration with expiratory wheezing and diminished breath sounds while assessing a patient. What does the nurse suspect? 1. Tuberculosis 2. Asthma 3. Pneumonia 4. Croup

2. Asthma --> Asthma impairs airway movement, which contributes to wheezes and decreased breath sounds. Tuberculosis typically is associated with a cough, fever, and night sweats. Pneumonia is associated with a productive cough and fever. Croup is associated with labored breathing, fever, and a bark-like cough.

A nurse suspects a viral infection or upper respiratory allergies when the patient describes the sputum as being which color? 1. Green 2. Clear 3. Yellow 4. Pink tinged

2. Clear

On examination, a nurse finds the patient has a productive cough with green sputum and inspiratory crackles. What other findings does this nurse expect during the examination? Select all that apply. 1. Muffled sounds heard when the patient says "e-e-e" 2. Fever 3. Dull tones to percussion 4. A sharp, abrupt pain reported when patient breathes deeply 5. Increased vibration on vocal fremitus

2. Fever 3. Dull tones to percussion 4. A sharp, abrupt pain reported when patient breathes deeply 5. Increased vibration on vocal fremitus

1. Oxygen is exchanged for carbon dioxide in the alveolar membrane Which action would the nurse take to decrease retained secretions in an 11-year-old child hospitalized with an exacerbation of chronic bronchitis? 1. Administer oxygen as prescribed. 2. Increase fluid intake to at least 2000 mL/day. 3. Encourage the child to rest in the high-Fowler position. 4. Teach the child to gargle with a saline solution every 2 hours

2. Increase fluid intake to at least 2000 mL/day. -->O2 Should be humidified due to drying nature

The nurse is providing hygiene care to a immobile client who was admitted for exacerbation of chronic obstructive pulmonary disease (COPD). Which nursing intervention is correct when the client becomes short of breath during the care? 1. Obtain a pulse oximeter to determine the client's oxygen saturation level. 2. Put the client in a high Fowler position. 3. Darken the lights and provide a rest period of at least 15 minutes. 4. Continue the hygiene activities while reassuring the client

2. Put the client in a high Fowler position.

Which actions would the nurse take to obtain subjective data about a client's respiratory status? Select all that apply. One, some, or all responses may be correct. 1. Palpate the chest and back for masses. 2. Question the client about shortness of breath. 3. Check the hematocrit and hemoglobin values. 4. Inspect the skin and nails for integrity and color. 5. Ask the client about color and quantity of sputum

2. Question the client about shortness of breath. 5. Ask the client about color and quantity of sputum

The examiner notes a diaphragmatic excursion of 4 cm on the right side and 8 cm on the left side. What do these findings mean? 1. This is a normal finding because the right lung is larger than the left lung. 2. The patient may have a pleural effusion. 3. The patient may have a pneumothorax. 4. Asymmetric findings are common in well-conditioned adults.

2. The patient may have a pleural effusion. --> Fluid in the pleural space can be detected by noting a difference in diaphragmatic excursion. A pneumothorax will be evidenced by decreased lung sounds and changes in percussion tone on the affected side. Measurements should be bilaterally equal. Measurements should be bilaterally equal.

The nurse assesses a patient who has a costal angle greater than 90 degrees. What is the most likely cause of this finding? 1. Infant respiratory distress syndrome 2. Pneumothorax 3. Chronic obstructive pulmonary disease 4. Atelectasis

3. Chronic obstructive pulmonary disease

A nurse finds the patient's AP diameter of the chest to be the same as the lateral diameter. Based on this finding, what additional data would the nurse anticipate? 1. Bronchial breath sounds in the posterior thorax 2. Decrease in respiratory rate 3. Decreased breath sounds on auscultation 4. Complaint of sharp chest pain on inspiration

3. Decreased breath sounds on auscultation

The nurse is providing care in the post--anesthesia care unit to a client who underwent a left pneumonectomy. Which nursing intervention is critical when the client regains consciousness? 1. Assessing for pain 2. Assessing for gag reflex 3. Encouraging deep breathing 4. Encouraging ankle pump exercises

3. Encouraging deep breathing

A patient has an infection of the terminal bronchioles and alveoli that involves the right lower lobe of the lung. Which abnormal findings are expected? 1. Dyspnea with diminished breath sounds bilaterally 2. Asymmetric chest expansion and rhonchi on the right side 3. Fever and tachypnea with crackles over the right lower lobe 4. Prolonged expiration with an occasional wheeze in the right lower lobe

3. Fever and tachypnea with crackles over the right lower lobe

A client with cystic fibrosis asks why the percussion procedure is being performed. Which rationale would the nurse give to the client? 1. It relieves bronchial spasms. 2. It increases the depth of respirations. 3. It loosens pulmonary secretions. 4. It expels carbon dioxide from the lungs

3. It loosens pulmonary secretions.

After an abdominal cholecystectomy, the client refuses to take deep breaths and cough, saying, "It's too painful." Which action would the nurse take? 1. Give pain medication regularly as soon as possible. 2. Obtain a prescription to increase the client's pain medication. 3. Schedule coughing and deep-breathing exercises after analgesic has taken effect. 4. Substitute incentive spirometry for coughing and deep breathing.

3. Schedule coughing and deep-breathing exercises after analgesic has taken effect.

Which question will give the nurse additional information about the nature of a patient's dyspnea? 1. "Does your heart rate increase when you are short of breath?" 2. "How often do you see the physician?" 3. "Do you have a cough that occurs with the dyspnea?" 4. "How has this condition affected your day-to-day activities?"

4. "How has this condition affected your day-to-day activities?"

Which client has the highest risk of pneumonia 1. 16 Y/O. Poor Nutritional status. Last pneumococcal vaccination: Within last 3 months 2. 28 Y/O. Uses tobacco. Last pneumococcal vaccination: 2 Years ago 3. 45 Y/O. Consumes alcohol regularly. Last pneumococcal vaccination: 1 Year ago 4. 67 Y/O. Chronic lung disease. Last pneumococcal vaccination: More than 5 Years ago

4. 67 Y/O. Chronic lung disease. Last pneumococcal vaccination: More than 5 Years ago

A nurse in the emergency department is assessing a patient with a moderate left pneumothorax. What does this nurse expect to find during the respiratory examination? 1. Increased fremitus over the left chest 2. Tracheal deviation to the left side 3. Crepitus on the left chest during palpation 4. Distant to absent breath sounds over the left chest

4. Distant to absent breath sounds over the left chest

The nurse is caring for a postoperative client who had general anesthesia. Which independent nursing intervention would prevent an accumulation of secretions? 1. Postural drainage 2. Cupping the chest 3. Nasotracheal suctioning 4. Frequent changes of position

4. Frequent changes of position

The nurse instructs a client to breathe deeply to open collapsed alveoli. Which explanation could the nurse offer to explain the relationship between alveoli and improved oxygenation? 1. The alveoli need oxygen to live. 2. The alveoli have no direct effect on oxygenation. 3. Collapsed alveoli increase oxygen demand. 4. Oxygen is exchanged for carbon dioxide in the alveolar membrane

4. Oxygen is exchanged for carbon dioxide in the alveolar membrane

During inspection of the respiratory system the nurse documents which finding as abnormal? 1. Skin color consistent with patient's race 2. 1:2 ratio of anteroposterior to lateral diameter 3. Respiratory rate of 20 breaths per minute 4. Patient leaning forward with arms braced on the knees

4. Patient leaning forward with arms braced on the knees

A 4-month-old infant with severe tachypnea, flaring of the nares, wheezing, and irritability is admitted to the pediatric unit with bronchiolitis. Which clinical finding is associated with possible respiratory failure? 1. Expiratory wheezing 2. Intercostal retractions 3. Fine crackles on deep inspiration 4. Sudden absence of breath sounds

4. Sudden absence of breath sounds

How does the nurse palpate the chest for tenderness, bulges, and symmetry? 1. Uses the fist of the dominant hand to gently tap the anterior, lateral, and posterior chest, comparing one side with another 2. Uses the ulnar surface of one hand to palpate the anterior, posterior, and lateral chest, comparing one side with another 3. Uses the tips of the fingers to palpate the skin over the chest and the alignment of vertebrae 4. Uses the palmar surface of fingers of both hands to feel the texture of the skin over the chest and the alignment of vertebrae

4. Uses the palmar surface of fingers of both hands to feel the texture of the skin over the chest and the alignment of vertebrae

The student nurse is reviewing the pathophysiology of inspiration. The primary muscles of inspiration are the diaphragm and the ____________. 1. scalene muscles 2. abdominal muscles 3. pectoral muscles 4. external intercostal muscles

4. external intercostal muscles -->Helps push the chest wall outward