Respiratory (Test)

A nurse is providing discharge teaching to a client who has COPD regarding the influenza vaccine. Which of the following statements should the nurse make?

"You should make every effort to receive a flu vaccine every year" **The nurse should explain to the client that the Centers for Disease Control and Prevention recommends that everyone older than 6 months of age should receive an annual influenza vaccine. Influenza can cause serious respiratory complications, even death, especially in those who are immunocompromised.

A nurse is reviewing the medical record of a client who was assessed as having a barrel chest resulting from COPD. Which of the following images shows a client who has a barrel chest?

A. A barrel chest is caused by hyperinflation of the lungs due to a disease process, such as COPD. It can also be associated with the normal aging process. The anterior/posterior to transverse diameter is equal, and the ribs, normally in a downward slope, lay horizontal. The client might sit in a tripod position to obtain adequate oxygen exchange.

A nurse is preparing to auscultate a client's posterior and lateral chest. In which order should the nurse perform the following actions?

1. Expose the posterior chest with the client sitting with their arms folded across their chest. 2. Auscultate 8 cm (3in) to one side of the spine around c7, then auscultate the other side of the spine in the same location. 3. Auscultate down the spine, moving the stethoscope from one side to the other until the lower thoracic spine is reached. 4. Auscultate the lateral sides slightly below the axillary area, then down to the seventh or eighth rib.

A nurse is auscultating the breath sounds of a client who has pneumonia and hears bronchial crackles. In which of the following areas of the chest is the nurse auscultating?

A. **Bronchial breath sounds are heard to the right and left of the trachea and larynx. They can only be heard on the anterior chest.

A nurse is providing teaching to a client who has a new diagnosis of asthma and reports a smoking history of 20 years. Which of the following statements should the nurse make when counseling the client about their tobacco use?

"smoking is linked to various forms of cancer", "it might take several attempts to finally stop smoking", and "there are pharmacologic therapies that can help a person stop smoking"

A charge nurse is teaching a newly licensed nurse how to recognize a pleural friction rub. Which of the following descriptions should the nurse use to describe a pleural friction rub?

Coarse grating tone, Heard on inspiration and expiration, and pain with breathing.

A nurse is caring for a client who is having difficulty breathing. Which of the following actions should the nurse take first?

Elevate the head of the client's bed. **According to evidence-based practice, the first action the nurse should take is to elevate the head of the client's bed. Raising the head of the bed to a semi- or high-Fowler's position will allow for improved lung expansion, which can facilitate air and gas exchange.

A charge nurse is reviewing the documentation of a newly licensed nurse. Which of the following entries made by the newly licensed nurse is an example of correct documentation?

Inspiratory wheeze auscultated at left lateral chest. **This entry is documented correctly. It is objective, descriptive, and based on facts. This information provides an accurate picture of the client's respiratory assessment for all providers.

A nurse is assessing a client who is dark-skinned. In which of the following areas of the client's body should the nurse assess the client for adequate oxygenation?

Nail beds, oral mucosa, and lips.

A nurse is caring for a client who is experiencing episodes of hyperventilation. Which of the following manifestations should the nurse expect during hyperventilation?

Numbness and tingling of extremities, lightheadedness, and chest pain.

A nurse is admitting a client who has a new diagnosis of COPD. Which of the following information documented by the nurse is subjective data?

Report from client says they sleep while propped on two pillows at night, client says they quit smoking 2 years ago, and client states, "Being short of breath all of the time is making me depressed"

A nurse is performing a head-to-toe assessment of a client. Which of the following findings indicate that client might be experiencing respiratory difficulty?

The client is sitting in a tripod position, the client is using pursed lipped breathing, and the client appears confused.

A charge nurse is observing a newly licensed nurse perform an anterior chest auscultation on a client. For. which of the following actions should the charge nurse intervene?

The nurse is auscultating through the client's gown. **The charge nurse should intervene because the stethoscope should be placed directly on the client's skin during auscultation. Auscultating through clothing can produce crackling or other abnormal sounds and obstruct air movement.

A charge nurse is teaching a newly licensed nurse how to recognize manifestations of decreased oxygenation in a client. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

"Clubbing of the fingers indicates a chronic state of impaired perfusion" **Clubbing of the ends of the fingers can indicate a chronic state of decreased oxygenation and perfusion.

A nurse in the emergency department is assessing a client who has experienced thoracic trauma from a motor-vehicle crash. Which of the following findings is an indication of a pneumothorax?

The client is experiencing unequal movement of the posterior chest. **When a pneumothorax, or collapsed lung, occurs, there is unequal expansion of the posterior chest. The client will be tachypneic with decreased or absent breath sounds on the affected side. A chest tube to re-inflate the lung is required to reverse a pneumothorax.

A nurse is auscultating the lateral lobes of a client who has bronchitis. The nurse should document the sounds as which of the following?

Wheeze. **A respiratory wheeze is a whistling, high-pitched musical sound made as air flows through narrowed passages. Wheezing can occur with conditions such as asthma and bronchitis because a client's airways are narrowed by edema.

A nurse is caring for a client who is dying and is having periods of deep breathing alternating with periods of apnea. The nurse should identify this as which of the following types of breathing?

Cheyne-Stokes breathing. **Cheyne-Stokes breathing can occur if the central nervous system is grossly affected by lack of oxygen or disease progression. It appears to have a respiratory "start-stop" breathing pattern. The client will have a deeper breath that might quicken, followed by hypoventilation and progression to apnea. This is an end-of-life breathing pattern.