MedSurg-chpt 20 Respiratory
The nurse is caring for clients on the neurological unit. Which triad of neurological mechanisms does the nurse identify as most responsible when there is abnormality in ventilation control?
Aortic arch, pons, and CO2 receptor sites
tactile fremitus
Asking the patient to repeat "ninety-nine" as the nurse's hands move down the patient's thorax
Which respiratory volume is the maximum volume of air that can be inhaled after maximal expiration?
Inspiratory reserve volume
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 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
tidal volume
amount of air inspired and expired with each breath
residual volume
amount of air remaining in the lungs after forcibly exhaling
dead space volume
amount of air remaining in the upper airways that never reaches the alveoli
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 client appears to be breathing faster than during the last assessment. Which of the following interventions should the nurse perform?
count respirations
A nurse is preparing a client for bronchoscopy. Which instruction should the nurse give to the client?
dont eat
High or increased compliance occurs in which disease process?
emphysema
The Family Nurse Practitioner is performing a physical examination of a client. The Nurse Practitioner examines the client's anterior, posterior, and lateral chest walls. What is the Nurse Practitioner assessing?
evidence of muscle weakness
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
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 client to hold his breath
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 ox
vital capacity
maximum amount of air that can be moved out of the lungs after maximal inspiration and expiration
Upon palpation of the sinus area, what would the nurse identify as a normal finding?
no sensation during palation
which area of the brain would the nurse realize is responsible for the rate and depth
pons
A nurse is preparing a client with a pleural effusion for a thoracentesis. The nurse should:
position the client sitting upright next to the bedside with hands resting on bedside table
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
he nurse is admitting a client who just had a bronchoscopy. Which assessment should be the nurse's priority?
swallow reflex
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 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?
theyre heard during inspiration and expiration
