NSG 245- Ch 20 Assessment of Respiratory Function
The client has just had an invasive procedure to assess the respiratory system. What does the nurse know should be assessed on this client?
Signs of respiratory distress & blood-streaked sputum
The nurse auscultated a patient's middle lobe of the lungs for abnormal breath sounds. To do this, the nurse placed the stethoscope on the:
Anterior surface of the right side of the chest, between the fourth and fifth rib. Explanation: The middle lobe of the lung is only found on the right side of the thorax and can only be assessed anteriorly. It is located at the fourth rib, at the right sternal border and extends to the fifth rib, in the midaxillary line.
A nurse is preparing a client for bronchoscopy. Which instruction should the nurse give to the client?
Do not eat or drink for 6 hours before the procedure.
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
A patient exhibited signs of an altered ventilation-perfusion ratio. The nurse is aware that adequate ventilation but impaired perfusion exists when the patient has which of the following conditions?
Pulmonary embolism Explanation: When a blood clot exists in a pulmonary vessel (embolus), impaired perfusion results. However, ventilation is adequate. With the other choices, ventilation is impaired but perfusion is adequate.
An client is described as having pectus carinatum. What would be the physical manifestation of this condition?
The sternum protrudes and the ribs are sloped backward. Explanation: Also known as pigeon chest, in this congenital anomaly, the sternum abnormally protrudes and the ribs are sloped backward. A depressed sternum would be considered funnel chest, or pectus excavatum. S-shaped spinal curvature would be considered scoliosis. A rounded chest would be considered barrel chest in which the anteroposterior diameter increases to equal the transverse diameter.
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. Explanation: Skin color doesn't affect the mucous membranes. Therefore, the nurse can assess for cyanosis by inspecting the client's mucous membranes. The lips, nail beds, and earlobes are less-reliable indicators of cyanosis because they're affected by skin color.
In relation to the structure of the larynx, the cricoid cartilage is
the only complete cartilaginous ring in the larynx.
Which hollow tube transports air from the laryngeal pharynx to the bronchi?
trachea
A nurse is instructing a client who is scheduled for a perfusion lung scan. What teaching should the nurse include in the information about the procedure? Select all that apply.
A mask will be placed over the nose and mouth during the test. The client will be expected to lie under the camera. The imaging time will amount to 20 to 40 minutes. Explanation: A ventilation/perfusion lung scan is performed by injecting a radioactive agent into a peripheral vein and then obtaining a scan of the chest to detect radiation. The isotope particles pass through the right side of the heart and are distributed into the lungs in proportion to the regional blood flow, making it possible to trace and measure blood perfusion through the lung. This procedure is used clinically to measure the integrity of the pulmonary vessels relative to blood flow and to evaluate blood flow abnormalities, as seen in pulmonary emboli. The imaging time is 20 to 40 minutes, during which the client lies under the camera with a mask fitted over the nose and mouth. Imaging is followed by the ventilation component of the scan. The client need not be NPO for 12 hours prior to the procedure. The radioactive agent will be injected into a peripheral vein not into the lung.
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 When monitoring clients after a pulmonary angiography, nurses must notify the health care provider 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?
An infection with pneumococcal pneumonia Explanation: Sputum that is rust colored suggests infection with pneumococcal pneumonia. Bronchiectasis and a lung abscess usually are associated with purulent thick and yellow-green sputum. Bronchitis usually yields a small amount of purulent sputum.
The ED nurse is assessing the respiratory function of a teenage girl who presented with acute shortness of breath. Auscultation reveals continuous wheezes during inspiration and expiration. This finding is most suggestive what?
Asthma Sibilant wheezes are commonly associated with asthma. They do not normally accompany pleurisy, emphysema, or pneumonia.
In a patient diagnosed with increased intracranial pressure (IICP), the nurse would expect to observe which of the following respiratory rate or depth?
Bradypnea Bradypnea is a slower than normal rate (<10 breaths/minute), with normal depth and regular rhythm. It is associated with IICP, brain injury, central nervous system depressants, and drug overdose. Tachypnea is associated with metabolic acidosis, septicemia, severe pain, and rib fracture. Hypoventilation is shallow, irregular breathing. Hyperventilation is an increased rate and depth of breathing.
A client arrives in the emergency department reporting shortness of breath. She has 3+ pitting edema below the knees, a respiratory rate of 36 breaths per minute, and heaving respirations. The nurse auscultates the client's lungs to reveal coarse, moist, high-pitched, and non-continuous sounds that do not clear with coughing. The nurse will document these sounds as which type?
Crackles Explanation: Crackles are adventitious breath sounds that are high-pitched, discontinuous, and popping; they may or may not clear with coughing and are moist. Often crackles are associated with heart failure.
The nurse is completing a patients health history with regard to potential risk factors for lung disease. What interview question addresses the most significant risk factor for respiratory diseases?
Do you currently smoke, or have you ever smoked? Smoking the single most important contributor to lung disease, exceeds the significance of environmental, occupational, and genetic factors.
The medical nurse who works on a pulmonology unit is aware that several respiratory conditions can affect lung tissue compliance. The presence of what condition would lead to an increase in lung compliance?
Emphysema High or increased compliance occurs if the lungs have lost their elasticity and the thorax is overdistended, in conditions such as emphysema. Conditions associated with decreased compliance include pneumothorax, hemothorax, pleural effusion, pulmonary edema, atelectasis, pulmonary fibrosis, and ARDS.
The nurse knows that what condition is associated with increased compliance of the lungs?
Emphysema Explanation: Compliance is normal if the lungs and the thorax easily stretch and distend. Increased compliance occurs if the lungs have lost their elastic recoil and become overdistended as in emphysema. Decreased compliance occurs if the lungs and the thorax are "stiff." Conditions associated with decreased compliance include morbid obesity, pneumothorax, hemothorax, pleural effusion, pulmonary edema, atelectasis, pulmonary fibrosis, and acute respiratory distress syndrome (ARDS). This causes airway collapse during expiration, dyspnea, and eventually cyanosis.
During a preadmission assessment, for what diagnosis would the nurse expect to find decreased tactile fremitus and hyperresonant percussion sounds?
Emphysema Explanation: Emphysema is associated with decreased tactile fremitus and hyperresonant percussion sounds. Bronchitis is associated with normal tactile fremitus and resonant percussion sounds. Atelectasis is associated with absent tactile fremitus and dull percussion sounds. Pulmonary edema is associated with normal tactile fremitus and resonant percussion sounds.
A client is seen in the emergency room for a case of diabetic acidosis with the presence of Kussmaul respirations. What client condition is associated with the presence of Kussmaul respirations?
Hyperventilation Explanation: Hyperventilation is an increased rate and depth of breathing that results in decreased PaCO2 levels and inspiration and expiration nearly equal in duration This is associated with exertion, anxiety, and metabolic acidosis. This hyperventilation is called Kussmaul respiration if associated with diabetic ketoacidosis or renal origin. Bradypnea is breaths slower than 10 per minute. Tachypnea is rapid, shallow breathing exceeding 24 breaths per minute. Hypoventilation is shallow, irregular breathing.
The nurse is caring for a patient with a lower respiratory tract infection. When planning a focused respiratory assessment, the nurse should know that this type of infection most often causes what?
Impaired gas exchange
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 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." In carcinoma, the pain may be dull and persistent because the cancer has invaded the chest wall, mediastinum, or spine.
The nurse is caring for a patient who has a pleural effusion and who underwent a thoracoscopic procedure earlier in the morning. The nurse should prioritize assessment for which of the following?
Shortness of breath Follow-up care in the health care facility and at home involves monitoring the patient for shortness of breath (which might indicate a pneumothorax).
A patient with a decreased level of consciousness is in a recumbent position. How should the nurse best assess the lung fields for a patient in this position?
Turn the patient to enable assessment of all the patients lung fields
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 Explanation: Several mechanisms control ventilation. The respiratory center in the medulla oblongata and pons control rate and depth of respirations. The central chemo receptors in the medulla and peripheral chemo receptors in the aortic arch also provide a mechanism for detecting abnormalities and signal changes to alter the pH and levels of oxygen in the blood. The other options have an incorrect piece of the triad.
The patient has just had an MRI ordered because a routine chest x-ray showed suspicious areas in the right lung. The physician suspects bronchogenic carcinoma. An MRI would most likely be order to assess for what in this patient?
Chest wall invasion MRI is used to characterize pulmonary nodules; to help stage bronchogenic carcinoma (assessment of chest wall invasion); and to evaluate inflammatory activity in interstitial lung disease, acute pulmonary embolism, and chronic thrombolytic pulmonary hypertension. Imaging would not focus on the alveoli since the problem in the bronchi. A static image such as MRI cannot inform
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. 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 patient diagnosed with diabetic ketoacidosis would be expected to have which type of respiratory pattern?
Kussmaul respirations
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 Explanation: When the minute ventilation falls, alveolar ventilation in the lungs also decreases, and the PaCO2 increases.
A young adult visited a clinic because he was injured during a softball game. He told the nurse that the ball struck him in his "Adam's apple." To assess the initial impact of injury, the nurse:
Palpates the thyroid cartilage. Explanation: The term "Adam's Apple" is used to refer to a lump or protrusion, a laryngeal prominence. It is formed by the angle of the thyroid cartilage surrounding the larynx.
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?
Sibilant wheezes Explanation: A decrease in airway diameter, such as in asthma, produces breath sounds of wheezes. Wheezes may be sibilant (hissing or whistling) or sonorous (full and deep). Sibilant wheezes (formerly called wheezes) are continuous musical sounds that can be heard during inspiration and expiration. They result from air passing through narrowed or partially obstructed air passages and are heard in clients with increased secretions. Sonorous wheezes (formerly called rhonchi) are lower pitched and are heard in the trachea and bronchi. Sonorous wheezes are coarse, rattling sounds similar to snoring usually caused by secretion in the bronchial tree. Crackles, also called rales, are crackling or rattling sounds signifying fluid or exudate in the lung fields. Rubs are secretions that can be heard in the large airway.
You are caring for a client admitted with chronic bronchitis. The client is having difficulty breathing, and the family asks you what causes this difficulty. What would be your best response?
"Conditions such as chronic bronchitis cause thickening of the bronchial mucosa so it makes it harder to breathe." Conditions that may alter bronchial diameter and affect airway resistance include contraction of bronchial smooth muscle (e.g., asthma); thickening of bronchial mucosa (e.g., chronic bronchitis); airway obstruction by mucus, a tumor, or a foreign body; and loss of lung elasticity (e.g., emphysema).
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." Explanation: The nurse would clarify the client's statement of improper breathing technique. During a pulmonary function test using a spirometer, a nose clip prevents air from escaping through the client's nose when blowing into the spirometer. All other statements are correct.
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" During a pulmonary angiography, a contrast medium is injected into the femoral circulation. When the medium is infused, the client will feel warm and flushed, with a possibility of chest pain. The client will feel pressure when the catheter is inserted. The client does not typically feel light-headed or nauseated during this procedure.
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 has recently been diagnosed with malignant lung cancer. The nurse is calculating the client's smoking history in pack-years. The client reports smoking two packs of cigarettes a day for the past 11 years. The nurse correctly documents the client's pack-years as
22 pack-years
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% Explanation: Normal SpO2 values are more than 95%. Values less than 90% indicate that the tissues are not receiving enough oxygen, in which case further evaluation is needed.
The clinic nurse is caring for a patient who has been diagnosed with emphysema and who has just had a pulmonary function test (PFT) ordered. The patient asks, What exactly is this test for? What would be the nurses best response?
A PFT measures how much air moves in and out of your lungs when you breathe. PFTs are routinely used in patients with chronic respiratory disorders. They are performed to assess respiratory function and to determine the extent of dysfunction. Such tests include measurements of lung volumes, ventilatory function, and the mechanics of breathing, diffusion, and gas exchange. Lung elasticity and diffusion can often be implied from PFTs, but they are not directly assessed. Energy obtained from respiration is not measured directly
A nurse would question the accuracy of a pulse oximetry evaluation in which of the following conditions?
A client experiencing hypothermia SpO2 values obtained by pulse oximetry are unreliable in states of low perfusion such as hypothermia.
The nurse is assessing a newly admitted medical patient and notes there is a depression in the lower portion of the patients sternum. This patients health record should note the presence of what chest deformity?
A funnel chest A funnel chest occurs when there is a depression in the lower portion of the sternum, and this may lead to compression of the heart and great vessels, resulting in murmurs. A barrel chest is characterized by an increase in the anteroposterior diameter of the thorax and is a result of overinflation of the lungs. A pigeon chest occurs as a result of displacement of the sternum and includes an increase in the anteroposterior diameter. Kyphoscoliosis, which is characterized by elevation of the scapula and a corresponding S-shaped spine, limits lung expansion within the thorax.
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 ABGs determine the blood's pH, oxygen-carrying capacity, levels of oxygen, CO2, and bicarbonate ion. 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.
A patient is being treated for a pulmonary embolism and the medical nurse is aware that the patient suffered an acute disturbance in pulmonary perfusion. This involved an alteration in what aspect of normal physiology?
Adequate flow of blood through the pulmonary circulation.
Which is a true statement regarding air pressure variances?
Air is drawn through the trachea and bronchi into the alveoli during inspiration. Explanation: Air flows from a region of higher pressure to a region of lower pressure. During inspiration, movement of the diaphragm and other muscles of respiration enlarge the thoracic cavity, thereby lowering the pressure inside the thorax to a level below that of atmospheric pressure.
The nurse is performing a respiratory assessment of a patient who has been experiencing episodes of hypoxia. The nurse is aware that this is ultimately attributable to impaired gas exchange. On what factor does adequate gas exchange primarily depend?
An adequate ventilation-perfusion ratio
The nurse is caring for a patient admitted with an acute exacerbation of chronic obstructive pulmonary disease. During assessment, the nurse finds that the patient is experiencing increased dyspnea. What is the most accurate measurement of the concentration of oxygen in the patients blood?
An arterial blood gas (ABG) study The arterial oxygen tension (partial pressure or PaO2 ) indicates the degree of oxygenation of the blood, and the arterial carbon dioxide tension (partial pressure or PaCO2 ) indicates the adequacy of alveolar ventilation. ABG studies aid in assessing the ability of the lungs to provide adequate oxygen and remove carbon dioxide and the ability of the kidneys to reabsorb or excrete bicarbonate ions to maintain normal body pH. Capillary blood samples are venous blood, not arterial blood, so they are not as accurate as an ABG. Pulse oximetry is a useful clinical tool but does not replace ABG measurement, because it is not as accurate. A CBC does not indicate the concentration of oxygen.
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 has assessed a patients family history for three generations. The presence of which respiratory disease would justify this type of assessment?
Asthma Asthma is a respiratory illness that has genetic factors. Sleep apnea, pneumonia, and pulmonary edema lack genetic risk factors.
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 Explanation: The presence of both inspiratory and expiratory wheezing usually signifies asthma if the individual does not have heart failure. Sudden dyspnea is an indicator of the other choices.
The nurse inspects the thorax of a patient with advanced emphysema. What does the nurse expect the chest configuration to be for this patient?
Barrel chest
While assessing an acutely ill patients respiratory rate, the nurse assesses four normal breaths followed by an episode of apnea lasting 20 seconds. How should the nurse document this finding?
Biots respiration The nurse will document that the patient is demonstrating a Biots respiration pattern. Biots respiration is characterized by periods of normal breathing (three to four breaths) followed by varying periods of apnea (usually 10 seconds to 1 minute). Cheyne-Stokes is a similar respiratory pattern, but it involves a regular cycle where the rate and depth of breathing increase and then decrease until apnea occurs. Biots respiration is not characterized by the increase and decrease in the rate and depth, as characterized by Cheyne-Stokes. Eupnea is a normal breathing pattern of 12 to 18 breaths per minute. Bradypnea is a slower-than-normal rate (<10 breaths per minute), with normal depth and regular rhythm, and no apnea
What finding by the nurse may indicate that the client has chronic hypoxia?
Clubbing of the fingers 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. Cyanosis can be a very late indicator of hypoxia, but it is not a reliable sign of hypoxia.
The nurse is caring for an elderly patient in the PACU. The patient has had a bronchoscopy, and the nurse is monitoring for complications related to the administration of lidocaine. For what complication related to the administration of large doses of lidocaine in the elderly should the nurse assess?
Confusion and lethargy Lidocaine may be sprayed on the pharynx or dropped on the epiglottis and vocal cords and into the trachea to suppress the cough reflex and minimize discomfort during a bronchoscopy. After the procedure, the nurse will assess for confusion and lethargy in the elderly, which may be due to the large doses of lidocaine administered during the procedure. The other listed signs and symptoms are not specific to this problem
A patient has been diagnosed with heart failure that has not yet responded to treatment. What breath sound should the nurse expect to assess on auscultation?
Crackles Crackles reflect underlying inflammation or congestion and are often present in such conditions as pneumonia, bronchitis, and congestive heart failure. Rhonchi and wheezes are associated with airway obstruction, which is not a part of the pathophysiology of heart failure.
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 patient with pulmonary edema would be expected to have crackles in the lung bases, and possible wheezes. Egophony may occur in patients diagnosed with pleural effusion. Absent breath sounds occurs in pneumothorax. Bronchial breath sounds occur in consolidation, such as pneumonia.
The nurse is assessing a patient in respiratory failure. What finding is a late indicator of hypoxia?
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. Cyanosis appears when there is at least 5 g/dL of unoxygenated hemoglobin.
A gerontologic nurse is analyzing the data from a patients focused respiratory assessment. The nurse is aware that the amount of respiratory dead space increases with age. What is the effect of this physiological change?
Decreased diffusion capacity for oxygen The amount of respiratory dead space increases with age. Combined with other changes, this results in a decreased diffusion capacity for oxygen with increasing age, producing lower oxygen levels in the arterial circulation. Decreased shunting and increased ventilation do not occur with age.
Which is an age-related change associated with the respiratory system?
Decreased size of the airway Age-related changes that occur in the respiratory system are a decrease in the size of the airway, decreased chest muscle mass, increased thickening of the alveolar membranes, and decreased elasticity of the alveolar sacs.
While conducting the physical examination during assessment of the respiratory system, which conditions does the 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 Nurses must determine if the client has any allergies, particularly to iodine, shellfish, or contrast dye. During the procedure, the nurse should check for signs and symptoms of allergic reactions to the contrast medium, such as itching, hives, or difficulty in breathing. The nurses inspects for hematoma, absent distal pulses, after the procedure. When the contrast medium is infused, an urge to cough is often a sensation experienced by the client.
The nurse doing rounds at the beginning of a shift notices a sputum specimen in a container sitting on the bedside table in a patients room. The nurse asks the patient when he produced the sputum specimen and he states that the specimen is about 4 hours old. What action should the nurse take?
Discard the specimen and assist the patient in obtaining another specimen.
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 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 tympanic sound is a high-pitched sound commonly heard over the stomach or bowel. A resonant sound is noted over normal lung tissue. A hyper resonant sound is an abnormal lower pitched sound that occurs when free air exists in disease processes such as pneumothorax.
While assessing a patient who has pneumonia, the nurse has the patient repeat the letter E while the nurses auscultates. The nurse notes that the patients voice sounds are distorted and that the letter A is audible instead of the letter E. How should this finding be documented?
Egophony This finding would be documented as egophony, which can be best assessed by instructing the patient to repeat the letter E. The distortion produced by consolidation transforms the sound into a clearly heard A rather than E. Bronchophony describes vocal resonance that is more intense and clearer than normal. Whispered pectoriloquy is a very subtle finding that is heard only in the presence of rather dense consolidation of the lungs. Sound is so enhanced by the consolidated tissue that even whispered words are heard. Sonorous wheezes are not defined as a voice sound, but rather as a breath sound.
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 Explanation: Tactile fremitus is assessed through vibrations of sound on the chest wall by palpation. Normally, fremitus is felt most over the large bronchi and least over the distant lung fields. Clients with emphysema exhibit almost no fremitus, because of the rupture of alveoli and the trapping of air. Air does not conduct sound well.
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 Explanation: The nurse examines the anterior, posterior, and lateral chest walls to check for lesions, symmetry, deformities, skin color, and evidence of muscle weakness or weight loss. The nurse examines the posterior pharynx and tonsils with a tongue blade and light to detect any difficulty in swallowing or hoarseness. The nurse inspects and gently palpates the trachea to assess the placement and deviation from the midline.
The nurse is assessing the respiratory status of a patient who is experiencing an exacerbation of her emphysema symptoms. When preparing to auscultate, what breath sounds should the nurse anticipate?
Faint breath sounds with prolonged expiration
A sputum study has been ordered for a patient who has developed coarse chest crackles and a fever. At what time should the nurse best collect the sample?
First thing in the morning Sputum samples ideally are obtained early in the morning before the patient has had anything to eat or drink.
A client with sinus congestion complains of discomfort when the nurse is palpating the supraorbital ridges. What sinus is the client referring?
Frontal Explanation: The nurse may palpate the frontal and maxillary sinuses for tenderness. Using the thumbs, the nurse applies gentle pressure in an upward fashion at the supraorbital ridges (frontal sinuses) and in the cheek area adjacent to the nose (maxillary sinuses). The ethmoidal sinuses are located between the nose and eyes. The sphenoidal sinuses are behind the nose between the eyes.
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 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 medical nurse has admitted a patient to the unit with a diagnosis of failure to thrive. The patient has developed a fever and cough, so a sputum specimen has been obtained. The nurse notes that the sputum is greenish and that there is a large quantity of it. The nurse notifies the patients physician because these symptoms are suggestive of what?
Infection The nature of the sputum is often indicative of its cause. A profuse amount of purulent sputum (thick and yellow, green, or rust-colored) or a change in color of the sputum is a common sign of a bacterial infection. Pink-tinged mucoid sputum suggests a lung tumor. Profuse, frothy, pink material, often welling up into the throat, may indicate pulmonary edema. A pneumothorax does not result in copious, green sputum.
What would the instructor tell the students purulent fluid indicates?
Infection Explanation: A small amount of fluid lies between the visceral and parietal pleurae. When excess fluid or air accumulates, the physician aspirates it from the pleural space by inserting a needle into the chest wall. This procedure, called thoracentesis, is performed with local anesthesia. 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. Purulent fluid is the recommended diagnosis for infection. Serous fluid may be associated with cancer, inflammatory conditions, or heart failure.
A pediatrician diagnosed a child with swollen and inflamed adenoids. The nurse practitioner confirmed the diagnosis by:
Inspecting the roof of the nasopharynx. The adenoids are clusters of lymph tissue located between the back of the nose and the back of the throat in the nasopharynx. The adenoids are usually inspected by using a special mirror. They cannot be seen by looking directly into the mouth.
A patient is scheduled to have excess pleural fluid aspirated with a needle in order to relieve her dyspnea. The patient inquires about the normal function of pleural fluid. What should the nurse describe?
It lubricates the movement of the thorax and lungs.
A patient is undergoing testing to see if he has a pleural effusion. Which of the nurses respiratory assessment findings would be most consistent with this diagnosis?
Lung fields dull to percussion, absent breath sounds, and a pleural friction rub
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. Explanation: Assessment of lung sounds includes auscultation for airflow through the bronchial tree. The nurse evaluates for fluid or solid obstruction in the lung. When airflow is decreased, as with fluid or secretions, adventitious sounds may be auscultated. Often crackles are heard with fluid in the airways.
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. What is the reason the client with suspected lung cancer would undergo magnetic resonance imaging (MRI)?
MRI can view soft tissues and can help stage cancers.
The nurse is caring for a patient with lung metastases who just underwent a mediastinotomy. What should be the focus of the nurses postprocedure care?
Maintaining the patients chest tube Chest tube drainage is required after mediastinotomy. PFT, chest physiotherapy, and oral suctioning would all be contraindicated because of the patients unstable health status
A patient on the medical unit has told the nurse that he is experiencing significant dyspnea, despite that he has not recently performed any physical activity. What assessment question should the nurse ask the patient while preparing to perform a physical assessment?
On a scale from 1 to 10, how bad would rate your shortness of breath? Gauging the severity of the patients dyspnea is an important part of the nursing process. Oral intake and nausea are much less important considerations. The nurse must perform assessment prior to interventions such as providing medication.
When assessing a client, which adaptation indicates the presence of respiratory distress?
Orthopnea 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 with suspected lung cancer. Which imaging study is more accurate than computed tomography in detecting malignancies?
PET Explanation: PET is more accurate than CT in detecting malignancies, and it has equivalent accuracy in detecting malignant nodules when compared with invasive procedures such as thoracoscopy. A gallium scan is used to stage bronchogenic cancer and document tumor regression after chemotherapy or radiation. MRI is used to characterize pulmonary nodules, to help stage bronchogenic carcinoma, and to evaluate inflammatory activity in interstitial lung disease. Pulmonary angiography is used to investigate thromboembolic disease of the lungs.
A patient asks the nurse why an infection in his upper respiratory system is affecting the clarity of his speech. Which structure serves as the patients resonating chamber in speech?
Paranasal sinuses A prominent function of the sinuses is to serve as a resonating chamber in speech. The trachea, also known as the windpipe, serves as the passage between the larynx and the bronchi. The pharynx is a tubelike structure that connects the nasal and oral cavities to the larynx. The pharynx also functions as a passage for the respiratory and digestive tracts. The major function of the larynx is vocalization through the function of the vocal cords. The vocal cords are ligaments controlled by muscular movements that produce sound.
The nurse is assessing a patient who frequently coughs after eating or drinking. How should the nurse best follow up this assessment finding?
Perform a swallowing assessment.
A patient has been diagnosed with pulmonary hypertension, in which the capillaries in the alveoli are squeezed excessively. The nurse should recognize a disturbance in what aspect of normal respiratory function?
Perfusion Perfusion is influenced by alveolar pressure. The pulmonary capillaries are sandwiched between adjacent alveoli and, if the alveolar pressure is sufficiently high, the capillaries are squeezed. This does not constitute a disturbance in ventilation (air movement), diffusion (gas exchange), or acidbase balance.
The nurse is caring for a patient who has returned to the unit following a bronchoscopy. The patient is asking for something to drink. Which criterion will determine when the nurse should allow the patient to drink fluids?
Presence of a cough and gag reflex After the procedure, it is important that the patient takes nothing by mouth until the cough reflex returns because the preoperative sedation and local anesthesia impair the protective laryngeal reflex and swallowing for several hours. Deep inspiration, adequate oxygen saturation levels, and absence of nausea do not indicate that oral intake is safe from the risk of aspiration
What is the primary function of the larynx?
Producing sound Explanation: The larynx, or voice box, is a cartilaginous framework between the pharynx and trachea. 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. Preventing infection is the main function of the tonsils and adenoids.
The clinical finding of pink, frothy sputum may be an indication of which condition?
Pulmonary edema Profuse frothy, pink material, often welling up into the throat, may indicate pulmonary edema. Foul-smelling sputum and bad breath may indicate a lung abscess, bronchiectasis, or an infection caused by fusospirochetal or other anaerobic organisms.
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 oximetry
In addition to heart rate, blood pressure, respiratory rate, and temperature, the nurse needs to assess a patients arterial oxygen saturation (SaO2 ). What procedure will best accomplish this?
Pulse oximetry Pulse oximetry is a noninvasive procedure in which a small sensor is positioned over a pulsating vascular bed. It can be used during transport and causes the patient no discomfort. An incentive spirometer is used to assist the patient with deep breathing after surgery. ABG measurement can measure SaO2, but this is an invasive procedure that can be painful. Some patients with asthma use peak flow meters to measure levels of expired air.
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 Rhonchi or sonorous wheezes are deep, low-pitched, rumbling sounds heard usually on expiration. The etiology of rhonchi is associated with chronic bronchitis. Crackles are soft, high-pitched sounds. Pleural friction rub is a creaking or grating sound not affected by coughing. Bronchial sounds are relatively high-pitched sounds.
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 Rhonchi or sonorous wheezes are deep, low-pitched, rumbling sounds heard usually on expiration. The etiology of rhonchi is associated with chronic bronchitis. Rales or crackles are soft, high-pitched sounds. A venous hum is a blood flow humming sound. Bronchovesicular sound is an intermediate pitch with expiration and inspiration.
The nurse is caring for a patient who has just returned to the unit after a colon resection. The patient is showing signs of hypoxia. The nurse knows that this is probably caused by what?
Shunting Shunting appears to be the main cause of hypoxia after thoracic or abdominal surgery and most types of respiratory failure. Impairment of normal diffusion is a less common cause. Infection would not likely be present at this early stage of recovery and nitrogen narcosis only occurs from breathing compressed air.
In which position should the client be placed for a thoracentesis?
Sitting on the edge of the bed If possible, place the client upright or sitting on the edge of the bed with the feet supported and arms and head on a padded over-the-bed table. Other positions in which the client could be placed include straddling a chair with the arms and head resting on the back of the chair, or 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 nurse is admitting a client who just had a bronchoscopy. Which assessment should be the nurse's priority?
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?
Take deep breaths and cough forcefully.
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. Explanation: The question asks for a documentation based on inspection. A funnel chest, known as pectus excavatum, has the sternum depressed from the second intercostal space, and it is more pronounced on inspiration. The nurse would not diagnose chronic respiratory disease or pneumonia. The nurse would also not prescribe a cough suppressant.
A patient has a diagnosis of multiple sclerosis. The nurse is aware that neuromuscular disorders such as multiple sclerosis may lead to a decreased vital capacity. What does vital capacity measure?
The maximal volume of air exhaled from the point of maximal inspiration Vital capacity is measured by having the patient take in a maximal breath and exhale fully through a spirometer. Vital lung capacity is the maximal volume of air exhaled from the point of maximal inspiration, and neuromuscular disorders such as multiple sclerosis may lead to a decreased vital capacity. Tidal volume is defined as the volume of air inhaled and exhaled with each breath. The volume of air in the lungs after a maximal inspiration is the total lung capacity. Inspiratory capacity is the maximal volume of air inhaled after normal expiration.
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?
The nursing assistant is pouring a glass of water to wet the client's mouth. 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.
The ED nurse is assessing a patient complaining of dyspnea. The nurse auscultates the patients chest and hears wheezing throughout the lung fields. What might this indicate?
The patient has a narrowed airway. Wheezing is a high-pitched, musical sound that is often the major finding in a patient with bronchoconstriction or airway narrowing. Wheezing is not normally indicative of pneumonia or hemothorax. Wheezing does not indicate the need for physiotherapy.
A nurse educator is reviewing the implications of the oxyhemoglobin dissociation curve with regard to the case of a current patient. The patient currently has normal hemoglobin levels, but significantly decreased SaO2 and PaO2 levels. What is an implication of this physiological state?
The patients tissue demands may be met, but she will be unable to respond to physiological stressors. With a normal hemoglobin level of 15 mg/dL and a PaO2 level of 40 mm Hg (SaO2 75%), there is adequate oxygen available for the tissues, but no reserve for physiological stresses that increase tissue oxygen demand. If a serious incident occurs (e.g., bronchospasm, aspiration, hypotension, or cardiac dysrhythmias) that reduces the intake of oxygen from the lungs, tissue hypoxia results.
A patient is having her tonsils removed. The patient asks the nurse what function the tonsils normally serve. Which of the following would be the most accurate response?
The tonsils help to guard the body from invasion of organisms.
The nurse is performing a respiratory assessment of an adult patient and is attempting to distinguish between vesicular, bronchovesicular, and bronchial (tubular) breath sounds. The nurse should distinguish between these normal breath sounds on what basis?
Their location over a specific area of the lung
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. Sibilant or hissing or whistling wheezes are continuous musical sounds that can be heard during inspiration and expiration. They result from air passing through narrowed or partially obstructed air passages and are heard in clients with increased secretions. The crackling or grating sounds heard during inspiration or expiration are friction rubs. They occur when the pleural surfaces are inflamed.
A patient with chronic lung disease is undergoing lung function testing. What test result denotes the volume of air inspired and expired with a normal breath?
Tidal volume Tidal volume refers to the volume of air inspired and expired with a normal breath. Total lung capacity is the maximal amount of air the lungs and respiratory passages can hold after a forced inspiration. Forced vital capacity is vital capacity performed with a maximally forced expiration. Residual volume is the maximal amount of air left in the lung after a maximal expiration.
A medical patient rings her call bell and expresses alarm to the nurse, stating, Ive just coughed up this blood. That cant be good, can it? How can the nurse best determine whether the source of the blood was the patients lungs?
Try to see if the blood is frothy or mixed with mucus. Though not definitive, blood from the lung is usually bright red, frothy, and mixed with sputum. Testing the pH of nonarterial blood samples is not common practice and would not provide important data. Similarly, oral suctioning and swabbing the patients mouth would not reveal the source.
A nurse is assessing a client's respiratory system. Which alveolar cells secrete surfactant to reduce lung surface tension?
Type II There are three types of alveolar cells. Type I and type II cells make up the alveolar epithelium. Type I cells account for 95% of the alveolar surface area and serve as a barrier between the air and the alveolar surface; type II cells account for only 5% of this area but are responsible for producing type I cells and surfactant. Surfactant reduces surface tension, thereby improving overall lung function. Alveolar macrophages, the third type of alveolar cells, are phagocytic cells that ingest foreign matter and, as a result, provide an important defense mechanism. Type IV is not a category of alveolar cells.
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. A high ventilation-perfusion rate means that ventilation exceeds perfusion, causing dead space. The alveoli do not have an adequate blood supply for gas exchange to occur. This is characteristic of a variety of disorders, including pulmonary emboli, pulmonary infarction, and cardiogenic shock.
What is the difference between respiration and ventilation?
Ventilation is the movement of air in and out of the respiratory tract. Explanation: Ventilation is the actual movement of air in and out of the respiratory tract. Respiration is the exchange of oxygen and CO2 between atmospheric air and the blood and between the blood and the cells.
The nurse is caring for a patient who has been scheduled for a bronchoscopy. How should the nurse prepare the patient for this procedure?
Withhold food and fluids for several hours before the test. Food and fluids are withheld for 4 to 8 hours before the test to reduce the risk of aspiration when the cough reflex is blocked by anesthesia.
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.
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.
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
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). Blood from the stomach is vomited rather than expectorated, may be mixed with food, and is usually much darker; it is often referred to as "coffee ground emesis." This blood has an acidic pH (<<7.0). Bloody sputum from the nose or the nasopharynx is usually preceded by considerable sniffing, with blood possibly appearing in the nose.
The nurse auscultates the lung sounds of a client 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
pleural friction rub. A pleural friction rub is heard secondary to inflammation and loss of lubricating pleural fluid. Crackles are soft, high-pitched, discontinuous popping sounds that occur during inspiration. Sonorous wheezes are deep, low-pitched rumbling sounds heard primarily during expiration. Sibilant wheezes are continuous, musical, high-pitched, whistle-like sounds heard during inspiration and expiration.
Pink, frothy sputum may be an indication of
pulmonary edema. Explanation: Profuse frothy, pink material, often welling up into the throat, may indicate pulmonary edema. Foul-smelling sputum and bad breath may indicate a lung abscess, bronchiectasis, or an infection caused by fusospirochetal or other anaerobic organisms.
The volume of air inhaled and exhaled with each breath is termed
tidal volume. Tidal volume is the volume of air inhaled and exhaled with each breath. Residual volume is the volume of air remaining in the lungs after a maximum expiration. Vital capacity is the maximum volume of air exhaled from the point of maximum inspiration. Expiratory reserve volume is the maximum volume of air that can be exhaled after a normal inhalation.
What is the purpose of the vascular and ciliated mucous lining of the nasal cavities?
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.
