Chapter 25 Assessment of respiratory system

Question 1

The primary purpose of the respiratory system is gas exchange. This involves?

Answer 1

transfer of O2 and CO2 between the atmosphere and blood. The respiratory system is divided into two parts: upper respiratory tract and lower respiratory tract

Question 2

The upper respiratory tract includes the?

Answer 2

nose, mouth, pharynx, epiglottis, larynx, and trachea

Question 3

Once air passes the carina, it is in the lower respiratory tract. The lower respiratory tract consists of the?

Answer 3

bronchi, bronchioles, alveolar ducts, and alveoli.

-lung lobes

Question 4

A patient with metabolic alkalosis has an SpO2 of 93% and a shift to the left in the oxygen-hemoglobin dissociation curve. Which action by the nurse is appropriate?

• Administer supplemental oxygen because less oxygen is dissolved in the blood.
• Discontinue supplemental oxygen because more oxygen is released to the tissues.
• Administer supplemental oxygen because oxygen is not readily released to the tissues.
• Discontinue supplemental oxygen because more oxygen is dissolved in the blood.

Answer 4

Administer supplemental oxygen because oxygen is not readily released to the tissues.

Question 5

A patient’s arterial blood gas (ABG) results include the following: pH 7.32, PaO2 84 mm Hg, PaCO2 49 mm Hg, and SaO2 84%. For what should the nurse assess the patient?
Tetany
Tachypnea
Pleural friction rub
Kussmaul respirations

Answer 5

Tachypnea

Question 6

The nurse would interpret an induration of 5 mm resulting from tuberculin skin testing as a positive finding in which patient?

A patient with a history of illegal IV drug use
A patient with diabetes and end-stage kidney disease
A patient who immigrated from India 3 months ago
A patient who is human immunodeficiency virus- infected

Answer 6

A patient who is human immunodeficiency virus- infected

Question 7

Gerontologic Considerations:Effects of Aging on Respiratory System
1) Structural changes
Chest wall stiffening
Costal cartilage calcification
↑ Anteroposterior diameter
↓ Elastic recoil
↓ Chest wall compliance
↓ Functioning alveoli
↓ Respiratory muscle strength 
2) Defense mechanisms
↓ Cell-mediated immunity
↓ Specific antibodies
↓ Cilia function
↓ Cough force
↓ Alveolar macrophage function
↓ Sensation in pharynx
3) Respiratory control
 ↓ Response to hypoxemia
↓ Response to hypercapnia

Answer 7

1) Structural changes
Chest wall stiffening- Barrel chest appearance, kyphotic posture, ↓ chest wall movement, ↓ deep breathing
Costal cartilage calcification
↑ Anteroposterior diameter
↓ Elastic recoil
↓ Chest wall compliance
↓ Functioning alveoli
↓ Respiratory muscle strength
2) Defense mechanisms
↓ Cell-mediated immunity
↓ Specific antibodies
↓ Cilia function
↓ Cough force
↓ Alveolar macrophage function
↓ Sensation in pharynx3) Respiratory control
↓ Response to hypoxemia
↓ Response to hypercapnia

Question 8

Assessment of Respiratory System: Subjective Data

Answer 8

• Important health information
• Past health history
• Medications
• Surgery or other treatments

Question 9

Subjective Data: Functional health patterns

Answer 9

• Health perception–health management pattern
• Nutritional‑metabolic pattern
• Elimination pattern
• Activity‑exercise pattern

Question 10

Objective Data

Answer 10

• Physical examination
• Nose
• Mouth and pharynx
• Neck