Chapter 17 - Assessment of Respiratory Function Flashcards
A client is having the tonsils removed. The client asks the nurse what function the tonsils normally serve. Which of the following would be the most accurate response?
A. “The tonsils separate your windpipe from your throat when you swallow.”
B. “The tonsils help to guard the body from invasion of organisms.”
C. “The tonsils make enzymes that you swallow and which aid with digestion.”
D. “The tonsils help with regulating the airflow down into your lungs.”
B. “The tonsils help to guard the body from invasion of organisms.”
Rationale: The tonsils, the adenoids, and other lymphoid tissue encircle the throat. These structures are important links in the chain of lymph nodes guarding the body from invasion of organisms entering the nose and throat. The tonsils do not aid digestion, separate the trachea from the esophagus, or regulate airflow to the bronchi.
The nurse is caring for a client who has just returned to the unit after a colon resection. The client is showing signs of hypoxia. The nurse knows that this is probably caused by:
A. nitrogen narcosis.
B. infection.
C. impaired diffusion.
D. shunting
D. shunting.
Rationale: Shunting appears to be the main cause of hypoxia after thoracic or abdominal surgery and most types of respiratory failure. Impairment of normal diffusion is a less common cause. Infection would not likely be present at this early stage of recovery, and nitrogen narcosis only occurs from breathing compressed air.
The nurse is assessing a client who frequently coughs after eating or drinking. How should the nurse best follow up this assessment finding?
A. Obtain a sputum sample.
B. Perform a swallowing assessment.
C. Inspect the client’s tongue and mouth.
D. Assess the client’s nutritional status.
B. Perform a swallowing assessment.
Rationale: Coughing after food intake may indicate aspiration of material into the tracheobronchial tree; a swallowing assessment is thus indicated. Obtaining a sputum sample is relevant in cases of suspected infection. The status of the client’s tongue, mouth, and nutrition is not directly relevant to the problem of aspiration.
The ED nurse is assessing a client who is reporting dyspnea. The nurse auscultates the client’s chest and hears wheezing throughout the lung fields. What might this indicate about the client?
A. Bronchoconstriction
B. Pneumonia
C. Hemoptysis
D. Hemothorax
A. Bronchoconstriction
Rationale: Wheezing is a high-pitched, musical sound that is often the major finding in a client with bronchoconstriction or airway narrowing. Wheezing is not normally indicative of pneumonia (an infection of the lungs), hemoptysis (the expectoration of blood from the respiratory tract), or hemothorax (a collection of blood in the space between the chest wall and the lung).
The nurse is caring for a client admitted with an acute exacerbation of chronic obstructive pulmonary disease. During assessment, the nurse finds that the client is experiencing increased dyspnea. What is the most accurate measurement of the concentration of oxygen in the client’s blood?
A. A capillary blood sample
B. Pulse oximetry
C. An arterial blood gas (ABG) study
D. A complete blood count (CBC)
C. An arterial blood gas (ABG) study
Rationale: The arterial oxygen tension (partial pressure or PaO2) indicates the degree of oxygenation of the blood, and the arterial carbon dioxide tension (partial pressure or PaCO2) indicates the adequacy of alveolar ventilation. ABG studies aid in assessing the ability of the lungs to provide adequate oxygen and remove carbon dioxide and the ability of the kidneys to reabsorb or excrete bicarbonate ions to maintain normal body pH. Capillary blood samples are venous blood, not arterial blood, so they are not as accurate as an ABG. Pulse oximetry is a useful clinical tool, but does not replace ABG measurement because it is not as accurate. A CBC does not indicate the concentration of oxygen.
The nurse is caring for a client who has returned to the unit following a bronchoscopy. The client is asking for something to drink. Which criterion will determine when the nurse should allow the client to drink fluids?
A. Presence of a cough and gag reflex
B. Absence of nausea
C. Ability to demonstrate deep inspiration
D. Oxygen saturation of greater than or equal to 92%
A. Presence of a cough and gag reflex
Rationale: After the procedure, it is important that the client takes nothing by mouth until the cough reflex returns because the preoperative sedation and local anesthesia impair the protective laryngeal reflex and swallowing for several hours. Deep inspiration, adequate oxygen saturation levels, and absence of nausea do not indicate that oral intake is safe from the risk of aspiration.
A client with chronic lung disease is undergoing lung function testing. What test result denotes the volume of air inspired and expired with a normal breath?
A. Total lung capacity
B. Forced vital capacity
C. Tidal volume
D. Residual volume
C. Tidal volume
Rationale: Tidal volume refers to the volume of air inspired and expired with a normal breath. Total lung capacity is the maximal amount of air the lungs and respiratory passages can hold after a forced inspiration. Forced vital capacity is vital capacity performed with a maximally forced expiration. Residual volume is the maximal amount of air left in the lung after a maximal expiration
In addition to heart rate, blood pressure, respiratory rate, and temperature, the nurse needs to assess a client’s arterial oxygen saturation (SaO2). What procedure will best accomplish this?
A. Incentive spirometry
B. Arterial blood gas (ABG) measurement
C. Peak flow measurement
D. Pulse oximetry
D. Pulse oximetry
Rationale: Pulse oximetry is a noninvasive procedure in which a small sensor is positioned over a pulsating vascular bed. It can be used during transport and causes the client no discomfort. An incentive spirometer is used to assist the client with deep breathing after surgery. ABG measurement can measure SaO2, but this is an invasive procedure that can be painful. Some clients with asthma use peak flow meters to measure levels of expired air.
A client asks the nurse why an infection in the upper respiratory system is affecting the clarity of the client’s speech. The nurse should describe the role of what structure?
A. Trachea
B. Pharynx
C. Paranasal sinuses
D. Larynx
C. Paranasal sinuses
Rationale: A prominent function of the sinuses is to serve as a resonating chamber in speech. The trachea, also known as the windpipe, serves as the passage between the larynx and the bronchi. The pharynx is a tube-like structure that connects the nasal and oral cavities to the larynx. The pharynx also functions as a passage for the respiratory and digestive tracts. The major function of the larynx is vocalization through the function of the vocal cords. The vocal cords are ligaments controlled by muscular movements that produce sound.
A client with a decreased level of consciousness is in a recumbent position. How should the nurse best assess the lung fields for a client in this position?
A. Review images from the client’s portable chest x-ray.
B. Turn the client to enable assessment of all lung fields.
C. Assess the breath sounds accessible from the anterior chest wall.
D. Assess oxygen saturation and, if low, reposition the client and auscultate breath sounds.
B. Turn the client to enable assessment of all lung fields.
Rationale: Assessment of the anterior and posterior lung fields is part of the nurse’s routine evaluation. If the client is recumbent, it is essential to turn the client to assess all lung fields so that dependent areas can be assessed for breath sounds, including the presence of normal breath sounds and adventitious sounds. Failure to examine the dependent areas of the lungs can result in missing significant findings. A chest x-ray does not allow assessment of breath sounds. Assessment of only breath sounds accessible from the anterior chest wall neglects breath sounds that can only be assessed in other lung fields. All lung fields need to be assessed whether oxygen saturation is low or not.
A client is undergoing testing to assess for a pleural effusion. Which of the nurse’s respiratory assessment findings would be most consistent with this diagnosis?
A. Increased tactile fremitus, egophony, and the chest wall dull on percussion
B. Decreased tactile fremitus, wheezing, and the chest wall hyperresonant on percussion
C. Lung fields dull to percussion, absent breath sounds, and a pleural friction rub
D. Normal tactile fremitus, decreased breath sounds, and the chest wall resonant on percussion
C. Lung fields dull to percussion, absent breath sounds, and a pleural friction rub
Rationale: Assessment findings consistent with a pleural effusion include affected lung fields being dull to percussion and absence of breath sounds. A pleural friction rub may also be present. The other listed signs are not typically associated with a pleural effusion.
The nurse doing rounds at the beginning of a shift notices a sputum specimen in a container sitting on the bedside table in a client’s room. The nurse asks when the client produced the sputum specimen, and the client states that the specimen is about 4 hours old. What action should the nurse take?
A. Immediately take the sputum specimen to the laboratory.
B. Discard the specimen and assist the client in obtaining another specimen.
C. Refrigerate the sputum specimen and submit it once it is chilled.
D. Add a small amount of normal saline to moisten the specimen.
B. Discard the specimen and assist the client in obtaining another specimen
Rationale: Sputum samples should be submitted to the laboratory as soon as possible. Allowing the specimen to stand for several hours in a warm room results in the overgrowth of contaminated organisms and may make it difficult to identify the pathogenic organisms. Refrigeration of the sputum specimen and the addition of normal saline are not appropriate actions
The nurse is assessing a newly admitted medical client and notes there is a depression in the lower portion of the client’s sternum. This client’s health record should note the presence of what chest deformity?
A. A barrel chest
B. A funnel chest
C. A pigeon chest
D. Kyphoscoliosis
B. A funnel chest
Rationale: A funnel chest occurs when there is a depression in the lower portion of the sternum, and this may lead to compression of the heart and great vessels, resulting in murmurs. A barrel chest is characterized by an increase in the anteroposterior diameter of the thorax and is a result of overinflation of the lungs. A pigeon chest occurs as a result of displacement of the sternum and includes an increase in the anteroposterior diameter. Kyphoscoliosis, which is characterized by elevation of the scapula and a corresponding S-shaped spine, limits lung expansion within the thorax.
The medical nurse who works on a pulmonology unit is aware that several respiratory conditions can affect lung tissue compliance. The presence of what condition would lead to an increase in lung compliance?
A. Emphysema
B. Pulmonary fibrosis
C. Pleural effusion
D. Acute respiratory distress syndrome (ARDS)
A. Emphysema
Rationale: High or increased compliance occurs if the lungs have lost their elasticity and the thorax is overdistended, such as in emphysema. Conditions associated with decreased compliance include pneumothorax, hemothorax, pleural effusion, pulmonary edema, atelectasis, pulmonary fibrosis, and ARDS.
A medical nurse has admitted a client to the unit with a diagnosis of failure to thrive. The client has developed a fever and cough, so a sputum specimen has been obtained. The nurse notes that the sputum is greenish and that there is a large quantity of it. The nurse notifies the client’s health care provider because these symptoms are suggestive of what issue?
A. Pneumothorax
B. Lung tumors
C. Infection
D. Pulmonary edema
C. Infection
Rationale: The nature of the sputum is often indicative of its cause. A profuse amount of purulent sputum (thick and yellow, green, or rust-colored) or a change in color of the sputum is a common sign of a bacterial infection. Pink-tinged mucoid sputum suggests a lung tumor. Profuse, frothy, pink material, often welling up into the throat, may indicate pulmonary edema. A pneumothorax does not result in copious, green sputum.
A client has been diagnosed with heart failure that has not yet responded to treatment. What breath sound should the nurse expect to assess on auscultation?
A. Expiratory wheezes
B. Inspiratory wheezes
C. Rhonchi
D. Crackles
D. Crackles
Rationale: Crackles reflect underlying inflammation or congestion and are often present in such conditions as pneumonia, bronchitis, and congestive heart failure. Rhonchi and wheezes are associated with airway obstruction, which is not a part of the pathophysiology of heart failure.
. A client has a diagnosis of multiple sclerosis. The nurse is aware that neuromuscular disorders such as multiple sclerosis may lead to a decreased vital capacity. What does vital capacity measure?
A. The volume of air inhaled and exhaled with each breath
B. The volume of air in the lungs after a maximal inspiration
C. The maximal volume of air inhaled after normal expiration
D. The maximal volume of air exhaled from the point of maximal inspiration
D. The maximal volume of air exhaled from the point of maximal inspiration
Rationale: Vital capacity is measured by having the client take in a maximal breath and exhale fully through a spirometer. Vital lung capacity is the maximal volume of air exhaled from the point of maximal inspiration, and neuromuscular disorders such as multiple sclerosis may lead to a decreased vital capacity. Tidal volume is defined as the volume of air inhaled and exhaled with each breath. The volume of air in the lungs after a maximal inspiration is the total lung capacity. Inspiratory capacity is the maximal volume of air inhaled after normal expiration.
While assessing an acutely ill client’s respiratory rate, the nurse assesses four normal breaths followed by an episode of apnea lasting 20 seconds. How should the nurse document this finding?
A. Eupnea
B. Apnea
C. Biot respiration
D. Cheyne-Stokes
C. Biot respiration
Rationale: The nurse will document that the client is demonstrating a Biot respiration pattern. Biot respiration is characterized by periods of normal breathing (three to four breaths) followed by varying periods of apnea (usually 10 seconds to 1 minute). Cheyne-Stokes is a similar respiratory pattern, but it involves a regular cycle where the rate and depth of breathing increase and then decrease until apnea occurs. Biot respiration is not characterized by the increase and decrease in the rate and depth, as characterized by Cheyne–Stokes. Eupnea is a normal breathing pattern of 12 to 18 breaths per minute.
The nurse is caring for an older client in the PACU. The client has had a bronchoscopy, and the nurse is monitoring for complications related to the administration of topical lidocaine. For what complication related to the administration of large doses of topical lidocaine in older adults should the nurse assess?
A. Decreased urine output and hypertension
B. Headache and vision changes
C. Confusion and lethargy
D. Jaundice and elevated liver enzymes
C. Confusion and lethargy
Rationale: Lidocaine may be sprayed on the pharynx or dropped on the epiglottis and vocal cords and into the trachea to suppress the cough reflex and minimize discomfort during a bronchoscopy. After the procedure, the nurse will assess for confusion and lethargy in an older adult, which may be due to the large doses of lidocaine given during the procedure. The other listed signs and symptoms are not specific to this problem
While assessing a client who has pneumonia, the nurse has the client repeat the letter E while the nurse auscultates. The nurse notes that the client’s voice sounds are distorted and that the letter A is audible instead of the letter E. How should this finding be documented?
A. Bronchophony
B. Egophony
C. Whispered pectoriloquy
D. Sonorous wheezes
B. Egophony
Rationale: This finding would be documented as egophony, which can be best assessed by instructing the client to repeat the letter E. The distortion produced by consolidation transforms the sound into a clearly heard A rather than E. Bronchophony describes vocal resonance that is more intense and clearer than normal. Whispered pectoriloquy is a very subtle finding that is heard only in the presence of rather dense consolidation of the lungs. Sound is so enhanced by the consolidated tissue that even whispered words are heard. Sonorous wheezes are not defined as a voice sound, but rather as a breath sound
The clinic nurse is caring for a client who has been diagnosed with emphysema and who has just had a pulmonary function test (PFT) ordered. The client asks, “What exactly is this test for?” What would be the nurse’s best response?
A. “A PFT measures how much air moves in and out of your lungs when you breathe.”
B. “A PFT measures how much energy you get from the oxygen you breathe.”
C. “A PFT measures how elastic your lungs are.”
D. “A PFT measures whether oxygen and carbon dioxide move between your lungs and your blood.”
A. “A PFT measures how much air moves in and out of your lungs when you breathe.”
Rationale: PFTs are routinely used in clients with chronic respiratory disorders. They are performed to assess respiratory function and to determine the extent of dysfunction. Such tests include measurements of lung volumes, ventilatory function, and the mechanics of breathing, diffusion, and gas exchange. Lung elasticity and diffusion can often be implied from PFTs, but they are not directly assessed. Energy obtained from respiration is not measured directly.
A client is being treated for a pulmonary embolism, and the medical nurse is aware that the client experienced an acute disturbance in pulmonary perfusion. This involved an alteration in which aspect of normal physiology?
A. Maintenance of constant osmotic pressure in the alveoli
B. Maintenance of muscle tone in the diaphragm
C. pH balance in the pulmonary veins and arteries
D. Adequate flow of blood through the pulmonary circulation
D. Adequate flow of blood through the pulmonary circulation
Rationale: Pulmonary perfusion is the actual blood flow through the pulmonary circulation. Perfusion is not defined in terms of pH balance, muscle tone, or osmotic pressure.
The nurse is performing a respiratory assessment of an adult client and is distinguishing between vesicular, bronchovesicular, and bronchial (tubular) breath sounds. How should the nurse distinguish between these normal breath sounds?
A. Their location over a specific area of the lung
B. The volume of the sounds
C. Whether they are heard on inspiration or expiration
D. Whether or not they are continuous breath sounds
A. Their location over a specific area of the lung
Rationale: Normal breath sounds are distinguished by their location over a specific area of the lung; they are identified as vesicular, bronchovesicular, and bronchial (tubular) breath sounds. Breath sounds are not distinguished solely on the basis of volume. Normal breath sounds are heard on both inspiration and expiration, and are continuous.
A client has been diagnosed with pulmonary hypertension, in which the capillaries in the alveoli are squeezed excessively. The nurse should recognize a disturbance in what aspect of normal respiratory function?
A. Acid–base balance
B. Perfusion
C. Diffusion
D. Ventilation
B. Perfusion
Rationale: Perfusion is influenced by alveolar pressure. The pulmonary capillaries are sandwiched between adjacent alveoli and, if the alveolar pressure is sufficiently high, the capillaries are squeezed. This does not constitute a disturbance in ventilation (air movement), diffusion (gas exchange), or acid–base balance
