Med surg 2. Chapter 20
A client appears to k9l887be breathing faster than during the last assessment. Which of the following interventions should the nurse perform?
Count the rate of respirations.
Pink frothy sputum may be an indication of
pulmonary edema.
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%
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
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 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
Which assessment finding would be most consistent with advanced emphysema?
Barrel-shaped 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
What finding by the nurse may indicate that the patient has chronic hypoxia?
Clubbing of the fingers
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
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?
Cyanosis
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
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.
During a preadmission assessment, for what diagnosis would the nurse expect to find decreased tactile fremitus and hyperresonant percussion sounds?
Emphysema
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
During a routine visit to the pulmonologist, a client is told to undergo a mediastinoscopy. After the physician leaves the room, the nurse enters and is asked about this procedure. How should the nurse respond?
Exploration and biopsy of the lymph nodes that drain the lungs
On arrival at the intensive care unit, a critically ill client suffers respiratory arrest and is placed on mechanical ventilation. The physician orders pulse oximetry to monitor the client's arterial oxygen saturation (SaO2) noninvasively. Which vital sign abnormality may alter pulse oximetry values?
Hypotension
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
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
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 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.
The nurse is caring for a patient who is scheduled for a bronchoscopy. The nurse understands that it is important to provide the required information and appropriate explanations for any diagnostic procedure to a patient with a respiratory disorder in order to do which of the following?+q
Manage decreased energy levels
Upon palpation of the sinus area, what would the nurse identify as a normal finding?
No sensation during palpation
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
Which of the following terms will the nurse use to document the inability of a patient to breathe easily unless positioned upright?
Orthopnea
The nurse is caring for a client with hypoxemia of unknown cause. Which of the following oxygen transport considerations does the nurse identify as crucial to circulate oxygen in the body system? Select all that apply.
Oxygen is dissolved. Oxyhemoglobin circulates to the body tissue. Adequate red blood cells are needed for oxygen transport.
The nurse is caring for a patient with suspected lung cancer. Which of the following imaging studies is more accurate in detecting malignancies than a CT scan?
PET scan
The nurse auscultates the lung sounds of a patient during a routine assessment. The sounds produced are harsh and cracking, sounding like two pieces of leather being rubbed together. The nurse would be correct in documenting this finding as which of the following?
Pleural friction rub
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
The nurse is taking a respiratory history for a patient who has come into the clinic with a chronic cough. What information should the nurse obtain from this patient? (Select all that apply.)
Previous history of lung disease in the patient or family Occupational and environmental influencesttb Previous history of smoking
A 53-year-old client sees the physician because he has had laryngitis for 2 weeks. After a thorough examination, the doctor orders medications and instructs the client to follow-up in 1 week if his voice has not improved. What is the primary function of the larynx?
Producing sound
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
In which position should the patient 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 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.
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 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.
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?
Tidal volume
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
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 assesses a client's respiratory status. Which observation indicates that the client is having difficulty breathing?
Use of accessory muscles
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.
What is the difference between respiration and ventilation?
Ventilation is the movement of air in and out of the respiratory tract.
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
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.
The amount of air inspired and expired with each breath is called:
tidal volume.
