CH 27: Respiratory Assessment Flashcards
The key anatomic landmark that separates the upper respiratory tract from the lower respiratory tract is the
a. carina.
b. larynx.
c. trachea.
d. epiglottis.
a. carina.
A patient asks, “How does air get into my lungs?” The nurse bases their answer on knowledge that air moves into the lungs because of
a. positive intrathoracic pressure.
b. contraction of the accessory abdominal muscles.
c. stimulation of the respiratory muscles by the chemoreceptors.
d. a decrease in intrathoracic pressure from an increase in thoracic cavity size.
d. a decrease in intrathoracic pressure from an increase in thoracic cavity size.
The nurse can best determine adequate arterial oxygenation of the blood by assessing
a. heart rate.
b. hemoglobin level.
c. arterial oxygen partial pressure.
d. arterial carbon dioxide partial pressure.
c. arterial oxygen partial pressure.
Defense mechanisms that help protect the lung from inhaled particles and microorganisms include the (select all that apply)
a. cough reflex.
b. mucociliary escalator.
c. alveolar macrophages.
d. reflex bronchoconstriction.
e. alveolar capillary membrane.
a. cough reflex.
b. mucociliary escalator.
c. alveolar macrophages.
d. reflex bronchoconstriction.
A student nurse asks the RN what can be measured by arterial blood gas (ABG). The RN tells the student that the ABG can measure (select all that apply)
a. acid-base balance.
b. bicarbonate (HCO3–).
c. mixed venous O2 (SvO2).
d. compliance and resistance.
e. partial pressure of O2 (PaO2).
a. acid-base balance.
b. bicarbonate (HCO3–).
e. partial pressure of O2 (PaO2).
To detect early signs or symptoms of inadequate oxygenation, the nurse would examine the patient for
a. dyspnea and hypotension.
b. apprehension and restlessness.
c. cyanosis and cool, clammy skin.
d. increased urine output and diaphoresis.
b. apprehension and restlessness.
During the respiratory assessment of an older adult, the nurse would expect to find (select all that apply)
a. a vigorous reflex cough.
b. increased chest expansion.
c. increased residual volume.
d. decreased lung sounds at base of lungs.
e. increased anteroposterior (AP) chest diameter.
c. increased residual volume.
d. decreased lung sounds at base of lungs.
e. increased anteroposterior (AP) chest diameter.
When assessing subjective data related to the respiratory health of a patient with emphysema, the nurse would ask about (select all that apply)
a. date of last chest x-ray.
b. dyspnea during rest or exercise.
c. pulmonary function test results.
d. ability to sleep through the entire night.
e. prescription and over-the-counter medication.
b. dyspnea during rest or exercise.
d. ability to sleep through the entire night.
e. prescription and over-the-counter medication.
When auscultating the chest of an older patient in mild respiratory distress, it is best to
a. begin listening at the apices.
b. begin listening at the lung bases.
c. begin listening on the anterior chest.
d. ask the patient to breathe through the nose with the mouth closed.
b. begin listening at the lung bases.
Which respiratory assessment finding does the nurse interpret as abnormal?
a. Inspiratory chest expansion of 1 inch
b. Symmetric chest expansion and contraction
c. Resonance (to percussion) over the lung bases
d. Bronchial breath sounds in the lower lung fields
d. Bronchial breath sounds in the lower lung fields
The nurse is preparing the patient for a diagnostic procedure to remove pleural fluid for analysis. The nurse would prepare the patient for which test?
a. Thoracentesis
b. Bronchoscopy
c. Pulmonary angiography
d. Sputum culture and sensitivity
b. Bronchoscopy
A patient with acute shortness of breath is admitted to the hospital. Which action should the nurse take during the initial assessment of the patient?
a. Ask the patient to lie down for complete a full physical assessment.
b. Complete the health history and check for allergies before treatment.
c. Briefly ask specific questions about this episode of respiratory distress.
d. Delay the physical assessment to first complete pulmonary function tests.
c. Briefly ask specific questions about this episode of respiratory distress.
Rationale: If respiratory distress is severe, only obtain pertinent information and defer a thorough assessment until the patient‘s condition stabilizes. Obtaining a comprehensive health history or full physical examination is unnecessary until the acute distress has resolved. Brief questioning and a focused physical assessment should be done rapidly to help determine the cause of the distress and suggest treatment. Checking for allergies is important, but it is not appropriate to complete the entire admission database at this time. the initial respiratory assessment must be completed before any diagnostic tests or interventions can be ordered.
The nurse prepares a patient who has a left-sided pleural effusion for a thoracentesis. How should the nurse position the patient?
a. High-Fowler‘s position with the left arm extended
b. Supine with the head of the bed elevated 30 degrees
c. On the right side with the left arm extended above the head
d. Sitting upright with the arms supported on an over bed table
d. Sitting upright with the arms supported on an over bed table
Rationale: The upright position with the arms supported increases lung expansion, allows fluid to collect at the lung bases, and expands the intercostal space so that access to the pleural space is easier. the other positions would increase the work of breathing for the patient and make it more difficult for the health care provider performing the thoracentesis.
The arterial blood gas (ABG) results of a patient with diabetes show metabolic acidosis.
Which compensatory finding would the nurse expect?
a. Intercostal retractions
b. Kussmaul respirations
c. Low oxygen saturation (SpO 2 )
d. Decreased venous O2 pressure
b. Kussmaul respirations
Rationale: Kussmaul (deep and rapid) respirations are a compensatory mechanism for metabolic acidosis. Acidosis does not cause intercostal retractions, a low oxygen saturation rate, or a decrease in venous O2 pressure.
On auscultation of a patient‘s lungs, the nurse hears low-pitched, bubbling sounds during inhalation in the lower third bilaterally. How should the nurse document this finding?
a. Inspiratory crackles at the bases
b. Expiratory wheezes in both lungs
c. Abnormal lung sounds in the apices of both lungs
d. Pleural friction rub in the right and left lower lobes
a. Inspiratory crackles at the bases
Rationale: Crackles are low-pitched, bubbling sounds usually heard on inspiration. Wheezes are high-pitched sounds. They can be heard during the expiratory or inspiratory phase of the respiratory cycle. the lower third of both lungs are the bases, not apices. Pleural friction rubs are grating sounds that are usually heard during both inspiration and expiration.
The nurse palpates the posterior chest and notes absent fremitus while the patient says “toy boat”. Which action would the nurse take next?
a. Palpate the anterior chest and observe for barrel chest.
b. Encourage the patient to turn, cough, and deep breathe.
c. Review the chest x-ray report for evidence of pneumonia.
d. Auscultate anterior and posterior breath sounds bilaterally.
d. Auscultate anterior and posterior breath sounds bilaterally.
Rationale: To assess for tactile fremitus, the nurse uses the palms of the hands to palpate for vibration while the patient repeats a word or phrase such as “toy boat.” After noting absent fremitus, the nurse would then auscultate the lungs to assess for the presence or absence of breath sounds. Absent fremitus may be noted with pneumothorax or atelectasis. the vibration is increased in conditions such as pneumonia, lung tumors, thick bronchial secretions, and pleural effusion. Turning, coughing, and deep breathing are appropriate interventions for atelectasis, but the nurse needs to first assess breath sounds. Fremitus is decreased if the hand is farther from the lung or the lung is hyperinflated (barrel chest). the anterior of the chest is more difficult to palpate for fremitus because of the presence of large muscles and breast tissue.
A patient with a chronic cough is scheduled to have a bronchoscopy with biopsy. Which intervention will the nurse implement directly after the procedure?
a. Encourage the patient to drink clear liquids.
b. Place the patient on bed rest for at least 4 hours.
c. Keep the patient NPO until the gag reflex returns.
d. Maintain the head of the bed elevated 90 degrees.
c. Keep the patient NPO until the gag reflex returns.
Rationale: Risk for aspiration and maintaining an open airway is the priority. Because a local anesthetic is used to suppress the gag and cough reflexes during bronchoscopy, the nurse should monitor for the return of these reflexes before allowing the patient to take oral fluids or food. the patient does not need to be on bed rest, and the head of the bed does not need to be in the high Fowler‘s position.
The nurse completes a shift assessment on a patient admitted in the early phase of heart failure.
Which sounds would the nurse most likely hear on auscultation?
a. Continuous rumbling, snoring, or rattling sounds mainly on expiration
b. Continuous high-pitched musical sounds on inspiration and expiration
c. Discontinuous high-pitched sounds of short duration during inspiration
d. Discontinuous low-pitched sounds of long duration during inspiration
c. Discontinuous high-pitched sounds of short duration during inspiration
Rationale: Fine crackles are likely to be heard in the early phase of heart failure. Fine crackles are discontinuous, high-pitched sounds of short duration heard on inspiration. Coarse crackles are a series of long-duration, discontinuous, low-pitched sounds during inspiration. Wheezes are continuous high-pitched musical sounds on inspiration and expiration.
A patient with respiratory disease experiences a decrease in SpO2 from 93% to 87% while ambulating. Which action would be the nurse‘s priority?
a. Notify the health care provider.
b. Administer PRN supplemental O2 .
c. Document the response to exercise.
d. Encourage the patient to pace activity.
b. Administer PRN supplemental O2 .
Rationale: The drop in SpO2 to 85% indicates that the patient is hypoxemic and needs supplemental O2 when exercising. the other actions are also important, but the first action would be to correct the hypoxemia.
The nurse teaches a patient about pulmonary spirometry testing. Which statement by the patient indicates teaching was effective?
a. “I should use my inhaler right before the test.”
b. “I won‘t eat or drink anything 8 hours before the test.”
c. “I will inhale deeply and blow out hard during the test.”
d. “My blood pressure and pulse will be checked every 15 minutes.”
c. “I will inhale deeply and blow out hard during the test.”
Rationale: For spirometry, the patient should inhale deeply and exhale as long, hard, and fast as possible. the other actions are not needed. the administration of inhaled bronchodilators should be avoided 6 hours before the procedure.
Which action by the nurse indicates a need to review respiratory assessment skills?
a. Compares breath sounds from side to side at each level.
b. Listens during the inspiratory phase, then moves the stethoscope.
c. Starts at the apices of the lungs, moving down toward the lung bases.
d. Instructs the patient to breathe slowly and deeply through the mouth.
b. Listens during the inspiratory phase, then moves the stethoscope.
Rationale: Listening only during inspiration indicates need for a review of respiratory assessment skills. At each placement of the stethoscope, listen to at least one cycle of inspiration and expiration. During chest auscultation, instruct the patient to breathe slowly and a little deeper than normal through the mouth. Auscultation should proceed from the lung apices to the bases, comparing opposite areas of the chest, unless the patient is in respiratory distress or will tire easily.
A patient who has a history of chronic obstructive pulmonary disease (COPD) was hospitalized for increasing shortness of breath and chronic hypoxemia (SaO2 levels of 89% to 90%). Which action by the nurse will be most effective in improving the patient‘s adherence with discharge teaching?
a. Have the patient repeat the instructions immediately after teaching.
b. Accomplish the patient teaching just before the scheduled discharge.
c. Arrange for the patient‘s caregiver to be present during the teaching.
d. Start giving the patient discharge teaching during the admission process.
c. Arrange for the patient‘s caregiver to be present during the teaching.
Rationale: Hypoxemia interferes with the patient‘s ability to learn and retain information, so having the patient‘s caregiver present will increase the likelihood that discharge instructions will be followed. Having the patient repeat the instructions will indicate that the information is understood at the time, but it does not guarantee retention of the information. Because the patient is likely to be distracted just before discharge, giving discharge instructions just before discharge is not ideal. the patient is likely to be anxious and even more hypoxemic than usual on the day of admission, so teaching about discharge should be postponed until the patient is stabilized.
A patient admitted to the emergency department with a sudden onset of shortness of breath is diagnosed with a possible pulmonary embolus. How would the nurse prepare the patient for diagnostic testing to confirm the diagnosis?
a. Ensure that the patient has been NPO.
b. Review lab results to evaluate renal function.
c. Inform radiology that radioactive glucose preparation is needed.
d. Instruct the patient to expect to inspire deeply and exhale forcefully.
b. Review lab results to evaluate renal function.
Rationale: Spiral computed tomography scans are the most commonly used test to diagnose pulmonary emboli and the contrast media used may impair renal function, so patients with existing renal impairment would need special preparation and post-procedure care. Bronchoscopy is used to detect changes in the bronchial tree, not to assess for vascular changes, and the patient should be NPO 6 to 12 hours before the procedure. Positron emission tomography scans are most useful in determining the presence of cancer and a radioactive glucose preparation is used. For spirometry, the patient is asked to inhale deeply and exhale as long, hard, and fast as possible.
Which patient statement indicates that a patient admitted with acute asthma may need teaching regarding medication use?
a. “I have not had any acute asthma attacks during the past year.”
b. “I became short of breath an hour before coming to the hospital.”
c. “I‘ve been taking acetaminophen every 6 hours for chest wall pain.”
d. “I‘ve used my albuterol inhaler frequently over the last 4 days.”
d. “I‘ve used my albuterol inhaler frequently over the last 4 days.”
Rationale: The increased need for a rapid-acting bronchodilator would alert the patient that an acute attack may be imminent and that a change in therapy may be needed. the patient would be taught to contact a health care provider if this occurs. the other data do not indicate any need for additional teaching.
A patient with acute dyspnea is scheduled for a spiral computed tomography (CT) scan.
Which information obtained by the nurse is a priority to communicate to the health care provider before theCT?
a. Allergy to shellfish
b. Apical pulse of 104
c. Respiratory rate of 30
d. O2 saturation of 90%
a. Allergy to shellfish
Rationale: Because iodine-based contrast media is used during a spiral CT, the patient may need to have the CT scan without contrast or be premedicated before injection of the contrast media. the increased pulse, low oxygen saturation, and tachypnea all indicate a need for further assessment or intervention but do not indicate a need to modify the CT procedure.
The nurse analyzes the results of a patient‘s arterial blood gases (ABGs). Which finding requires immediate action?
a. The bicarbonate level (HCO3-) is 31 mEq/L.
b. The arterial oxygen saturation (SaO 2 ) is 92%.
c. The partial pressure of CO2 in arterial blood (PaCO2) is 31 mm Hg.
d. The partial pressure of oxygen in arterial blood (PaO2) is 62 mm Hg.
d. The partial pressure of oxygen in arterial blood (PaO2) is 62 mm Hg.
Rationale: All the values are abnormal, but the low PaO2 indicates that the patient is at the point on the oxyhemoglobin dissociation curve where a small change in the PaO2 will cause a large drop in the O2 saturation and a decrease in tissue oxygenation. the nurse would intervene immediately to improve the patient‘s oxygenation.
Which assessment finding for an older patient indicates that the nurse should take immediate action?
a. Weak cough effort
b. Barrel-shaped chest
c. Dry mucous membranes
d. Bilateral basilar crackles
d. Bilateral basilar crackles
Rationale: Crackles in the lower half of the lungs indicate that the patient may have an acute problem such as heart failure. the nurse should immediately accomplish further assessments, such as O 2 saturation, and notify the health care provider. A barrel-shaped chest, and a weak cough effort are associated with aging and immediate action is not indicated. An older patient has a less forceful cough and fewer and less functional cilia. Mucous membranes tend to be drier.
After the nurse has received change-of-shift report, which patient would the nurse assess first?
a. A patient with pneumonia who has crackles in the right lung base
b. A patient with chronic bronchitis who has a low forced vital capacity
c. A patient with possible lung cancer who has just returned after bronchoscopy
d. A patient with hemoptysis and a 16-mm induration after tuberculin skin testing
c. A patient with possible lung cancer who has just returned after bronchoscopy
Rationale: Because the cough and gag are decreased after bronchoscopy, this patient would be assessed for airway patency. The other patients do not have clinical manifestations or procedures that require immediate assessment by the nurse.
The nurse assesses a patient with chronic obstructive pulmonary disease (COPD) who has been admitted after increasing dyspnea over the past 3 days. Which finding is important for the nurse to report to the health care provider?
a. Respirations are 36 breaths/min.
b. Anterior-posterior chest ratio is 1:1.
c. Lung expansion is decreased bilaterally.
d. Hyperresonance to percussion is present.
a. Respirations are 36 breaths/min.
Rationale: The increase in respiratory rate indicates respiratory distress and a need for rapid interventions such as administration of O 2 or medications. the other findings are common chronic changes occurring in patients with COPD.
Which action could the nurse delegate to assistive personnel (AP)?
a. Listen to a patient‘s lung sounds for wheezes or crackles.
b. Label specimens obtained during percutaneous lung biopsy.
c. Instruct a patient about how to use home spirometry testing.
d. Measure induration at the site of a patient‘s intradermal skin test.
b. Label specimens obtained during percutaneous lung biopsy.
Rationale: Labeling of specimens at the bedside during a procedure is within the scope of practice of AP. The other actions require nursing judgment and should be done by licensed nursing personnel.
The nurse is caring for a patient who has just had a thoracentesis. Which assessment information obtained by the nurse is a priority to communicate to the health care provider?
a. O2 saturation is 88%.
b. Blood pressure is 155/90 mm Hg.
c. Respiratory rate is 24 breaths/min when lying flat.
d. Pain level is 5 (on 0 to 10 scale) with a deep breath.
a. O2 saturation is 88%.
Rationale: O 2 saturation should improve after a thoracentesis. A saturation of 88% indicates that a complication such as pneumothorax may be occurring. the other assessment data also indicate a need for ongoing assessment or intervention, but the low O2 saturation is the priority.
A patient is scheduled for a computed tomography (CT) scan of the chest with contrast media.
Which assessment findings would the nurse report to the health care provider before the patient goes for the CT? (Select all that apply.)
a. Allergy to shellfish
b. Patient reports claustrophobia
c. Elevated serum creatinine level
d. Recent bronchodilator inhaler use
e. Inability to remove a wedding band
a. Allergy to shellfish
c. Elevated serum creatinine level
Rationale: Because the contrast media is iodine-based and may cause dehydration and decreased renal blood flow, asking about iodine allergies (such as allergy to shellfish) and monitoring renal function before the CT scan are necessary. the other actions are not contraindications for CT of the chest, although they may be for other diagnostic tests, such as magnetic resonance imaging or pulmonary spirometry.
