NURSU 454 Med Surg Respiratory Assessment
Which findings would the nurse expect when doing a respiratory assessment on a healthy young adult? Select all that apply. One, some, or all responses may be correct.
A midline trachea Deep pink nasal mucosa Respirations of 14 breaths per minute
An 8-year-old child with a history of asthma is brought to the emergency department because of respiratory distress. The nurse immediately places the child in a bed with the head of the bed elevated and administers oxygen by means of a face mask. The health care provider admits the child to the pediatric unit. Which orders should the nurse carry out first?
Administer the nebulizer treatment.
When the nurse auscultates a client's lungs and hears fine, high-pitched, popping sounds in the left lower lung as the client inhales, how would the finding be documented?
Inspiratory crackles
When the nurse is evaluating a client with an acute asthma attack who has just received a nebulized bronchodilator treatment, which finding requires the most rapid action?
Labored breathing and absent breath sounds
Which positioning would be avoided while assessing a client with a history of asthma?
Lateral recumbent
The nurse is providing postoperative care for an adult who is obese and who had major abdominal surgery. The client has a history of smoking three packs of cigarettes daily. Which lab/diagnostic finding will the nurse check for the most accurate measurement of the client's respiratory status?
Oxygen saturation
Which client would the nurse assess first after a shift report?
A 6-month-old with a croupy cough and inspiratory stridor with exertion
The nurse is assessing a client who reports shortness of breath. Which activity best ensures that the nurse obtains accurate and complete data to prevent a nursing diagnostic error?
Assess the client's lungs. The nurse would assess the client's lungs to gather objective data that will support subjective data provided by the client. The nurse can obtain objective data for this client by auscultating for lung sounds, assessing the respiratory rate, and measuring the client's chest excursion. The nurse would review the data for accuracy and completeness before grouping the data into clusters. The nurse may also assess the client for pain, which is subjective data. The client may provide details about smoking habits, which is also subjective data. It is important for the nurse to identify what causes shortness of breath; however, the client's statement is subjective data. All subjective data must be supported by measurable objective data.
The nurse noticed the respiratory rate as regular and slow while assessing a client. Which would be the condition of the client?
Bradypnea
The nurse is providing postoperative care to a client who underwent a partial pneumonectomy. When inspecting the client's dressing, the nurse notes puffiness of the tissue around the surgical site. When the nurse palpates the site, the tissue feels spongy and crackles can be felt. How would the nurse interpret the assessment findings?
Subcutaneous emphysema
When performing a focused respiratory assessment, which action would the nurse take first?
Check for any evidence of respiratory distress.
When caring for a client with emphysema who becomes more restless, which action would the nurse take first?
Check oxygen saturation Unexplained restlessness is an early sign of decreased oxygenation and the nurse will check oxygen saturation and then report abnormal findings to the health care provider. Auscultation of lung sounds is also appropriate, but oxygen saturation is a better indicator of hypoxemia. The nurse would observe for changes in respiratory effort, but oxygen saturation would provide better information about hypoxemia. Asking the client about dyspnea is also appropriate, but not as good an assessment tool for hypoxemia as oxygen saturation.
The nurse performs lung assessments of four clients. The details are given below. Which client has inflamed pleura?
Client D The breathing sounds in a pleural rub or an inflamed pleura are of a dry or grating quality that is heard in the lower portion of the anterior lateral lung, as observed in client D. High-pitched, continuous musical sounds heard all over the lung are wheezing breath sounds heard when there is high-velocity airflow through severely narrowed or an obstructed airway. Loud, low-pitched, rumbling coarse sounds heard in the trachea and bronchi are rhonchi, which are observed during muscular spasm or when fluid or mucus is present in the larger airways. Fine crackles, medium crackles, and coarse crackles heard in client C are heard in lung bases due to the random and sudden reinflation of groups of alveoli, which causes a disruptive passage of air through the small airways.
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?
Crackles
The client reports difficulty in breathing. The nurse auscultates lung sounds and assesses the respiratory rate. Which is the purpose of the nurse's action?
Data collection
The nurse is caring for a 4-year-old child who has been hospitalized with an acute asthma exacerbation. Which assessment finding would require immediate action by the nurse?
Diminished breath sounds
The nurse is caring for a client with emphysema. During assessment, the nurse expects to auscultate which type of breath sounds?
Diminished breath sounds Breath sounds will be decreased in clients with emphysema because of reduced airflow, pleural effusion, or lung parenchymal destruction. A pleural friction rub occurs when one layer of the pleural membrane slides over the other during breathing; this is associated with pleurisy. Crackles indicate fluid in the alveoli, which is associated with heart failure or infection; rhonchi signify airway obstruction, not emphysema. Expiratory wheezing and coughing are associated with asthma or bronchitis.
When a client with chronic obstructive pulmonary disease (COPD) is receiving oxygen, which assessment findings indicate increasing carbon dioxide (CO 2) retention? Select all that apply. One, some, or all responses may be correct.
Drowsiness Irregular pulse Mental confusion Because high oxygen saturation and high PaO 2 levels can depress respiratory drive in some (but not all) clients with COPD, the nurse will plan to assess for clinical manifestations of CO 2 retention when clients are receiving supplemental oxygen. CO 2 retention depresses the central nervous system, leading to drowsiness, confusion, and decreased respiratory depth and rate. CO 2 retention also affects cardiac function, leading to dysrhythmias. Lethargy, rather than anxiety, is seen with CO 2 retention because of central nervous system depression. Respiratory rate will decrease with CO 2 retention because of central nervous system depression.
Which assessments are the most significant for a client who is believed to have myasthenia gravis?
Effectiveness of respiratory exchange and ability to swallow Respiratory failure will require emergency intervention, and inability to swallow may lead to aspiration. Difficulty with chewing and speaking are signs of myasthenia gravis that may occur but are not life threatening. Ocular palsies and an inability to smile are signs of myasthenia gravis that may occur but are not life threatening. Although the client's level of anxiety and concerns about the diagnosis are important, they are not the most significant assessments.
A child admitted to the hospital with a diagnosis of status asthmaticus appears to be improving. Which is the most objective way for the nurse to evaluate the child's response to therapy?
Evaluating the child's peak expiratory flow rate
A client develops increased respiratory secretions because of radiation therapy to the lung, and the health care provider prescribes postural drainage. Which client assessment leads the nurse to determine that the postural drainage is effective?
Has a productive cough
After a spontaneous pneumothorax, a client's assessment findings include extreme drowsiness, tachycardia, and tachypnea. The nurse suspects which condition?
Hypercapnia Pneumothorax results in decreased surface area for gas exchange. If unaffected pleural regions cannot compensate, carbon dioxide builds up in the blood (hypercapnia). The client will become drowsy and may lose consciousness. The body attempts to compensate by increasing respiratory and pulse rates and by the kidneys retaining bicarbonate. Hypokalemia causes extreme muscle weakness, abdominal distention, and changes in the electrocardiogram (ECG) pattern. The PO 2 is decreased with a pneumothorax because of the decreased surface area for gas exchange. Respiratory acidosis occurs with an elevated PCO 2.
When palpating the chest during a respiratory assessment, which finding would the nurse expect in a client with pneumonia?
Increased fremitus over the affected area Fremitus is the vibration that can be felt on the chest wall when the client talks. Because vibration is carried more easily through denser tissue, increased fremitus is felt when palpating over the area of pneumonia than would normally be felt over air-filled alveoli. Pneumonia does not cause changes in bilateral chest expansion, which might be seen in a client with a chronic obstructive pulmonary disease, such as emphysema. Tracheal deviation away from the affected side would not occur with pneumonia, but might be seen in a client with a pleural effusion or pneumothorax. There is no decreased chest expansion of the affected side with pneumonia, but unilateral decrease in chest expansion might be seen in a client with pneumothorax or pleural effusion.
When a client is diagnosed with pneumonia, which findings would the nurse expect when assessing the chest?
Increased tactile (vocal) fremitus
Which finding in a client with asthma exacerbation requires the most rapid action by the nurse?
Markedly decreased breath sounds
Which is the priority assessment for the client who has Guillain-Barré syndrome with rapidly ascending paralysis?
Monitoring respiratory status
Which are the nurse's priority assessments of the breathing component of a primary survey of a client? Select all that apply. One, some, or all responses may be correct.
Observe for chest wall trauma. Assess breath sounds and respiratory effort. The priorities to check for breathing include observation of the chest wall for trauma and assessment of breath sounds and respiratory effort. Establishment of a patent airway by positioning occurs during the assessment of the airway and cervical spine. Level of consciousness is evaluated to determine mental status of the client. Clothing is removed to perform a complete physical assessment of the client.
Which action would the nurse take first when admitting a client, who has had a left-sided pneumonectomy, to the postanesthesia care unit?
Obtain oxygen saturation. Because assessment and maintenance of respiratory function is the priority in the immediate postoperative period, assessment of respiratory parameters such as oxygen saturation would be done first. The incision and dressings would be assessed for bleeding, but this would be done after assessing respiratory function. Blood pressure and pulse are monitored to help check for bleeding, but this would be done after assessing respiratory function. The chest tube is typically clamped after pneumonectomy, because reinflation of the lung is not needed, and no drainage is expected in the collection chamber.
Which finding would be of most concern when the nurse assesses a client with emphysema?
Oral cyanosis
The nurse assesses the vital signs of a 50-year-old female client and documents the results. Which are considered within normal range for this client? Select all that apply. One, some, or all responses may be correct.
Oral temperature of 98.2°F (36.8°C) Apical pulse of 88 beats/min and regular Blood pressure of 116/78 mm Hg while in a sitting position
An older client with shortness of breath is admitted to the hospital. The medical history reveals and a diagnosis of pneumonia 3 days ago. Which vital sign assessment would be seen as a sign that the client needs immediate medical attention?
Oxygen saturation: 89% An oxygen saturation of less than 90% observed in a client with pneumonia indicates that the client is at risk of respiratory depression. Oxygen saturation would take priority in initiating the care. The client's body temperature indicates fever due to pneumonia, which should be considered secondary to the oxygen saturation problem. The blood pressure reading is normal. The increased respiratory rate may be due to fever, which would be considered secondary to the oxygen saturation problem.
A client with a 10-year history of emphysema is hospitalized for acute respiratory distress. Which assessment finding would the nurse expect to identify?
Prolonged expiration with use of accessory muscles
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.
Question the client about shortness of breath. Ask the client about color and quantity of sputum. Subjective data is collected directly from the client. During the respiratory assessment, the nurse would ask the client about any shortness of breath and about the color and quantity of any sputum produced. Objective data is collected by the nurse through physical examination and laboratory reports. The nurse would palpate the chest and back for masses while collecting objective data during the physical examination. The nurse checks the hematocrit and hemoglobin values while collecting objective diagnostic data. The nurse inspects the client's skin and nails for integrity and color to determine oxygenation of tissues.
Before beginning administration of morphine via patient-controlled analgesia (PCA), which assessment would the nurse perform first?
Respirations
A client is admitted with metabolic acidosis. Which two body systems would the nurse assess for compensatory changes?
Respiratory and urinary
When assessing the breath sounds of a client with chronic obstructive pulmonary disease (COPD), the nurse hears moist rumbling sounds that improve after the client coughs. How will the nurse document the lung sounds?
Rhonchi Rhonchi are coarse and moist sounds caused by obstruction of the airway with thick mucus, and they usually clear or change with coughing as the mucus moves or is expectorated. Wheezes are high-pitched, continuous sounds. Fine crackles are high-pitched popping noises. Vesicular sounds are the normal breath sounds.
A client is experiencing severe acute respiratory distress. Which response would the nurse expect the client to exhibit?
Tachycardia
Which topic would the nurse plan to include in teaching a client with a new diagnosis of asthma?
Use of peak flow meter
Soft swishing sounds of breathing are heard when the nurse auscultates a client's chest. Which term would be used when documenting this assessment finding?
Vesicular breath sounds Vesicular breath sounds are expected respiratory sounds heard on auscultation as inspired air enters and leaves alveoli. Fine crackles are faint crackling sounds heard at the end of inspiration; they are associated with pulmonary edema. "Adventitious sounds" is a general term for all abnormal breath sounds. Diminished breath sounds are evidence of a decreased amount of air entering the alveoli; this usually is caused by obstruction or consolidation.
The nurse performs a respiratory assessment and auscultates breath sounds that are high pitched, creaking, and accentuated on expiration. Which term correctly describes the findings?
Wheezes
