Respiratory Exam 1
Acute Bronchitis
Rhonci heard in the upper lobes
Hoarseness
is due to a sore throat
1. Olfactory
Cranial Nerve 1 sensory recognizes smells
Pleural effusion
Collection of fluid in the pleural cavity
Stimulus to breath
Healthy person-CO2 too high COPD-oxygen is too low
atelectasis
- a collapsed lung. Literally, "an imperfect expansion" in Greek.
The nurse is caring for a long-term care facility resident who is in the final hours of life. Which assessment findings does the nurse expect to see? Select all that apply. 1. Difficulty swallowing. 2. Dyspnea 3. Bladder and bowel incontinence 4. Lethargy 5. Restlessness 6. Difficulty sleeping
1, 2, 3, 4, 5
The nurse enters the room where a patient has just died; the patient is surrounded by close family members. What would be appropriate actions for the nurse to take? Select all that apply. 1. Ask the family if they want a few minutes alone with the deceased. 2. Listen actively to the bereaved as they talk about the deceased. 3. Ask the bereaved to leave the room so that the body can be removed. 4. Ask if the family needs help in arranging transportation from the hospital. 5. Remind the family of relatives, church members, and friends that they may call on for assistance. 6. Wait until family members have left to turn off or remove monitors, oxygen, or IV fluids.
1, 2, 4, 5
The nurse is providing care for a 96-year-old patient who has a Do Not Resuscitate order. The nurse recognizes that which of the following nursing actions can be taken? Select all that apply. 1. Enteral tube feeding via a gastrostomy tube 2. Oral suctioning 3. Chest compressions 4. Telemetry 5. Turn the patient every 2 hours 6. Digoxin 0.25 mg QD
1, 2, 4, 5, 6
The nurse is assisting with a community education program on respiratory health. Which of the following are risk factors for the development of chronic obstructive pulmonary disease that should be included in the program? Select all that apply. 1. Air pollution 2. Influenza 3. Familial predisposition 4. Smoking 5. High-fat diet 6. History of tuberculosis
1, 3, 4
What is the survival rate for nursing home patients who have received cardiopulmonary resuscitation? 1. 1% to 2% 2. 4% to 5% 3. 5% to 15% 4. > 15%
1. 1% to 2%
Respiratory System Purpose
1. Acid Base regulation, removes CO2 2. Temperature control, breathes heat out 3. Cilia filters impurities, nasal hairs filter 4. Sound 5. Smell, olfactory nerve one, eating 6. Gas exchange
A patient is in acute distress because of retained secretions and inability to cough effectively. Assessment reveals oxygen saturation of 82% and respiratory rate of 28 breaths per minute. Which intervention should the nurse provide first? 1. Perform tracheal suctioning 2. Encourage fluids 3. Encourage the patient to increase activity 4. Assess the patient's coughing technique
1. Perform tracheal suctioning
The nurse is caring for an older patient at the end of life who is experiencing dyspnea related to lung cancer and pneumonia. The nurse administers diuretics and antibiotics as ordered. Which of the following patient outcomes indicates that use pf the medications has been effective? 1. The patient's respiratory rate is between 12 and 20 respirations per minute. 2. The patient's pulse is between 60 and 100 beats per minute. 3. The patient urinates frequently. 4. The patient is alert and oriented.
1. The patient's respiratory rate is between 12 and 20 respirations per minute.
The nurse is caring for a young adult patient who is experiencing dyspnea, syncope, and chest pain. The patient has a history of systemic lupus erythematosus. Which of the following diagnostic tests would the nurse anticipate? Select all that apply. 1. Antinuclear antibody titer 2. Pulmonary angiogram 3. Cardiac catheterization 4. Intravenous pyleogram 5. Chest x-ray 6. Arterial blood gas
2, 3, 5, 6
Which of the following patients is most at risk for atelectasis? 1. An individual occupationally exposed to metal and wood dust. 2. A postsurgical patient who does not cough and breathe deeply. 3. A patient with an infected pleural effusion 4. A patient with chronic gastroesophageal reflux disease.
2. A postsurgical patient who does not cough and breathe deeply.
The nurse is caring for a patient with a spontaneous closed pnemothorax. Which assessment finding requires immediate intervention? 1. An oxygen saturation result of 92% 2. Bradycardia and hypotension 3. Diminished breath sounds on the affected side. 4. Pale mucous membranes.
2. Bradycardia and hypotension
A 16-year-old student with alleric asthma plays soccer in an open field. Assuming the student has prescriptions for all the following medications, which should the nurse recommend be used before soccer games? 1. Zafirlukast (Accolate) 2. Cromolyn sodium (Intal) inhaler 3. Guaifenesin (Robitussin) 4. Methylprednisolone (Solu-Medrol) inhaler
2. Cromolyn sodium (Intal) inhaler
Which document specifies who will speak for the patient when the patient cannot speak for him- or herself? 1. Living will 2. Durable power of attorney 3. Patient Self-Determination Act 4. Health Insurance Portability and Accountability Act
2. Durable power of attorney
An 83-year-old patient who developed an infection after chemotherapy for bone cancer has now worsened and developed septicemia. New orders designate Do Not Resuscitate status with comfort measures. The patient is lethargic, sleeps frequently, and has labored breathing. What should the nurse expect to be prescribed? 1. Broad-spectrum antibiotics to treat the infection 2. Opioid drugs to ease pain and dyspnea. 3. A change in the chemotherapy regimen 4. A narcoleptic drug to increase the patient's alertness.
2. Opioid drugs to ease pain and dyspnea.
Chronic bronchitis is similar to acute bronchitis with symptoms occuring for at least ________ months out of the year for 2 consecutive years.
3
Which intervention takes priority for a patient with fractures of the fourth, fifth, sixth, and seventh ribs caused by a fall? 1. Placement of an elastic rib belt to stabilize the ribs. 2. Administration of oxygen. 3. Around-the-clock administration of analdesics as ordered. 4. Encouragement to cough and deep breathe
3. Around-the-clock administration of analdesics as ordered.
The physician has ordered sputum culture for acid-fast bacillus for a patient admitted with chronic productive cough and reported night sweats. Which of the following is the nurse's priority action? 1. Administer an expectorant as ordered. 2. Encourage the patient to cough and deep breath. 3. Ask the physician if isolation precautions are necessary while awaiting culture results. 4. Keep the patient's bed linens clean and dry.
3. Ask the physician if isolation precautions are necessary while awaiting culture results.
The nurse is caring for a patient recovering from surgery for a broken femur. Which of the following assessment findings would be most concerning to the nurse? 1. Severe pain in the affected limb 2. Nausea and vomiting. 3. Sudden onset of dyspnea. 4. Temperature of 101.4 F
3. Sudden onset of dyspnea.
Which patient is most likely to benefit from tube feeding and artificial hydration? 1. The patient who has multiple medical conditions and is declining. 2. The patient who is declining due to the aging process. 3. The patient who is unable to eat due to an acute illness. 4. The patient at the end of life who has copious pharyngeal and lung secretions.
3. The patient who is unable to eat due to an acute illness.
PaCo2
32-48 mmHg
The nurse is caring for a patient being treated with oxygen and antibiotics for right-sided lung disease and acute respiratory distress syndrome. In which of the following positions should the nurse place the patient? 1. High Fowler's 2. Prone 3. Supine 4. Left side-lying
4. Left side-lying
A patient diagnosed with a terminal illness who is expected to live only a few weeks suddenly experiences a high fever, increasing shortness of breath and respiration rate, and moist and noisy respiration. What would be the most appropriate action by the LPN who has documented these findings? 1. Inform the supervision RN that death is imminent. 2. Increase the frequency of monitoring the patient's vital signs. 3. Call the patient's physician. 4. Report the findings to the supervisory RN, and collaborate on planning care.
4. Report the findings to the supervisory RN, and collaborate on planning care.
The nurse assists with development of a nursing diagnosis of Impaired Gas Exchange for a patient with pneumonia. Which of the following patient outcomes indicates that interventions have been successful? 1. Pain rating of 3 on a 1-10 pain scale 2. Absence of adventitious lung sounds 3. Temperature and white blood cell count within normal limits. 4. SaO2 of 95%
4. SaO2 of 95%
It is estimated that by the year 2020, __________% of people will die in nursing homes.
50
pericarditis
A condition in which the sac-like covering around the heart (pericardium) becomes inflamed.
empyema
Accumulation of pus in the pleural cavity
meningitis
An acute inflammation of the meninges, usually caused by a viral or bacterial infection.
Lower Respiratory Tract
Bronchi, bronchioles (gas exchange begins), alveolar ducts, and alveoli
Gerontologic structural changes
Chest wall muscle strength alveoli all diminished normal pulse ox may be down to 92 barrel chest place hands on chest and check expansion equally on both sides?
Cardinal Symptom of Respiratory disease
Cough
10. Vagus
Cranial Nerve 10 motor and sensory viscera of thorax and abdomen (sensory) larynx middle and inferior pharyngeal muscles heart lung digestive system
11. Accessory
Cranial Nerve 11 motor sternocleidomastoid muscles and trapezius muscles
12. Hypoglossal
Cranial Nerve 12 Motor Muscles of the tongue
2. Optic
Cranial Nerve 2 Sensory Visual acuity in all visual fields in both eyes
3. Oculomotor
Cranial Nerve 3 Motor Eye movement except lateral gaze, shape of eyelid, pupil size
4. Trochlear
Cranial Nerve 4 Motor Downward inward gaze
5. Trigeminal
Cranial Nerve 5 Motor and Sensory Open and close mouth (motor) Cheek, maxialla, mandible (sensory)
6. Abducens
Cranial Nerve 6 Motor Lateral eye gaze
7. Facial
Cranial Nerve 7 Motor and Sensory face (motor) anterior 2/3 of tongue (sensory)
8. Vestibulocochlear
Cranial Nerve 8 Sensory equilibrium auditory
9. Glossopharyngeal
Cranial Nerve 9 motor and sensory pharynx and posterior tongue, taste (sensory) pharyngeal muscles (motor)
Pulmonary Emboli
Definitive testing is a CT scan, other types of testing are pulmonary angiography (check patient for iodine sensitivity)
Pulmonary Circulation
Deoxygenated blood from the body returns to the heart through the inferior and superior vena cava and empties into the RIGHT atrium. From there, the blood flows to the into the RIGHT ventricle. The RIGHT ventricle pumps blood through the pulmonary arteries and then into the lungs. Oxygenated blood travels from the lungs through the pulmonary veins and empties into the LEFT atrium then to the LEFT ventricle and out of the Aorta to the body.
Trachea
Divides into R-L side bronchi Right side is shorter and wider than left its where you are most likely to aspriate
Nose
Filters warms moistens air, very vascular, septum, turbinates incrase surface area
Fluid in space
Normal amount of fluid is 20-25 ml which provides lubrication If there is an increase a Chest X ray to determine if there is any build up of extra fluid Ultrasound then to determine how much thoracentisis to remove the fluid
arthritis
Inflammation of a joint
Control Center of Respiration
Medulla, in the back of the head. Any patient with head trauma or stroke, CNS depressants, expect to monitor breathing.
Upper Respiratory System Includes
Nose Pharynx adenoids-lumphatic tissue in nasopharynx tonsils epiglottis larynx trachea
S&S of inadequate oxygenation
RESTLESSNESS tachypnea tachycardia hypotension cyanosis accessory muscles coma
Lungs
The right lung has 3 lobes, Left lung has 2
Pharynx
The throat, nasopharynx, oropharynx, and laryngopharynx
Pleura
Visceral line the lungs Parietal lines the cavity (does have sensory pain fibers)
A patient is admitted to the hospital with shortness of breath. The nurse notes increasing confusion and combativeness during the past hour. Which of the following actions is appropriate first? a. Assess the patient; check to see if the oxygen is flowing correctly. b. Page the physician stat. c. Put up the patient's side rails and apply soft restrainst. d. Administer an intramuscular sedative.
a. Hypoxia can cause confusion and agitation.
A patient with end-stage COPD has a nursing diagnosis of 'Impaired Gas Exchange'. Which assessment finding shows that interventions have been effective? a. The patient's SpO2 is 97% on 2 liters of oxygen. b. The patient appears comfortable. c. The patient is coughing up copious white sputum. d. The patient is able to move in bed without difficulty.
a. SpO2 is the best measure of gas exchange.
Cheyne-Stokes
abnormal pattern of breathing characterized by alternating periods of apnea and deep rapid breathing
Defense mechanisms of the lungs
air filtration mucocilliary response cough bronchoconstriction macrophages
Nasal fracture nursing management
apply ice, any nasal surgery avoid NSAIDS up to two weeks before and after surgery
CO2
arterial should be 35-45
Which of the following assessment findings does the nurse expect in the patient with emphysema? a. Purulent sputum b. Diminished breath sounds c. Generalized edema d. Dull chest pain
b. Damaged alveoli and air trapping cause diminished breath sounds.
Which of the following interventions is most appropriate for the patient with an ineffective breathing pattern? a. Encourage the patient to cough and deep breathe. b. Teach the patient controlled diaphragmatic breathing. c. Encourage oral fluids d. Allow the patient to rest between activities.
b. Diaphragmatic breathing can help make the breathing pattern more effective.
The nurse is caring for a patient who has signed a Do Not Resuscitate document but is becoming increasingly anxious about pain and suffering in the last hours of life. The patient is alert and oriented. What would be an appropriate response from the nurse? a. Tell the patient that signing the Do Not Resuscitate order is irrevocable and that no changes can be made to the document. b. Explain to the patient that a Do Not Resuscitate order does not mean "do not treat," and discuss the range of treatment possibilities. c. Tell the patient that many patients become anxious at the end of life, and that medication is available to relieve the anxiety. d. Tell the patient that any changes in the Do Not Resuscitate status must be made by the patient's durable power of attorney.
b. Explain to the patient that a Do Not Resuscitate order does not mean "do not treat," and discuss the range of treatment possibilities.
Mediastinum
behind the sternum, it contains the heart and all the great vessels. Needs plenty of room if anything (blood, fluid, air) gets in and takes up the space it puts pressure on the lungs.
Nasal Packing
blocks bleeding, you should check the back of the throat for bleeding
Pursed Lip breathing
blowing off more CO2
A patient asks the nurse why he doesn't feel sick even though his TB test is positive. The nurse knows the patient has been diagnosed with LTBI. Which explanation is best to provide the patient? a. "TB often does not make people feel sick, but is is contagious nevertheless." b. "You have latent disease, which just stays in your system but won't ever make you sick." c. "You have TB infection, but not active disease. As long as your immune system stays strong, it can keep the infection from making you sick." d. "Even though you do not feel sick, the positive test shows that you have the disease and must be treated."
c. LTBI is a latent, not active, infection.
A patient with recurrent pneumothorax is scheduled to have pleurodesis done in one hour. Which nursing intervention should take priority at this time? a. Encourage fluids b. Encourage coughing and deep breathing c. Administer a prn analgesic as ordered. d. Administer a prn bronchodilator as ordered.
c. Pleurodesis is painful; a pain medication should be administered.
Which of the following assessment findings in the patient with pneumonia most indicates a need to remind the patient to cough and deep breathe? a. The patient reports chest pain. b. The patient has removed her oxygen. c. The patient develops coarse wheezes and crackles. d. The patient has a fever of 101 F (38.3 C)
c. Wheezes and crackles can signify sputum that needs to be coughed up
Collapsed Lung
can be from trauma or pressure change pleural cavity has negative pressure system if any air leaks into the space the pressure change can cause the collapse.
Pnuemothorax
collapsed lung from air
Surfactant
decreases surface tension to prevent lung collapse decreases the pressure needed to inflate. Deep breathing produces surfactant
A patient with shortness of breath is being tested for lung cancer. Which diagnostic test will be most conclusive? a. Chest x-ray b. MRI c. Sputum culture d. Biopsy
d. Biopsy is always the most definitive test for cancer.
Elastic Recoil
elasticity property of the lungs--ability to return back to the resting state, chest passively returns to smaller volume
Gerontologic defense changes
decreased immunity decreased antibodies decreased cough decreased secretion clearence infections are more severe and last longer
Thoracentisis
done at bedside usually after procedure CXR then place patient on unaffected side monitor V/S and lung sounds, breathing
Pneumonia
dyspnea or tachypnea fever weak rapid pulse abnormal lung sounds frequent cough pain in chest consolidation
Treatment
fluids to get secretions up
Tube feeding
head of the bed should always be up
Sinuses
hollow, make the head lighter, more surface area to warm the air, equalizes pressure, frontal maxillary sphenoid ethmoid
Bronchodilators
increase the lumen size tachycardia is a side effect you should check the pts. heart rate before and after as well as lung sounds before and afterwards Tremors
endocarditis
inflammation of the inner lining of the heart
bronchoconstriction
keeps oxygen from coming in, wheezing sounds, louder wheezing is better it means more air is going through the lung
Diaphragm
major muscle of respiration, can be worn out in the older population. Accessory muscles may be used in that case, abnormal respirations. Ex. sternocleidomastoid and intercostal muscles are used
mucocilliary response
mucus builds up in the bronchi to remove the bacteria and when the mucus builds up too much you have reduced lumen for air exchange
Endoscopy
must watch for apsiration, bleeding, numbing of throat, sedatoin, is trachea midline? PERFORATION-afebrile before treatment? then sudden fever afterwards?
Epistaxis
nose bleed, you pinch the soft part of the nose
Nasal degongestant spray
over the counter shouldnt be used for more than three days
Kassmaul
rapid, deep breathing
Right bronchus
shorter wider straighter more vertical, most likely the place where you will aspirate
Left bronchus
smaller more horizontal
SaO2
the amount of oxygen that is bound to the hemoglobin in comparison to the amount of oxygen the hemoglobin can carry, recorded as a percentage >95%
PaO2
the amount of oxygen which is dissolved in the plasma, recorded as mmHg, arterial oxygen 80-100
Compliance
the ease of which the lung expands
