Chapters 20-24, 26, 30 Flashcards
A client is being seen in the emergency department for exacerbation of COPD. The first action of the nurse is to administer which of the following prescribed treatments?
Oxygen through nasal cannula at 2 L/minute
A 55 y.o. pt is scheduled for spirometry testing for evaluation of chronic obstructive pulmonary disease (COPD). The nurse
Asks the client, “What are your allergies?”
A client has asthma. Which of the following medication is a commonly prescribed mast cell stabilizer used for asthma?
Cromolyn sodium
The instructor of the pre-nursing physiology class is explaining respiration to the class. What does the instructor explain is the main function of respiration?
To exchange oxygen and CO 2 between the atmospheric air and the blood and between the blood and the cells
A client with a suspected pulmonary disorder undergoes pulmonary function tests. To interpret test results accurately, the nurse must be familiar with the terminology used to describe pulmonary functions. Which term refers to the volume of airinhaled or exhaled during each respiratory cycle?
Tidal volume
The nurse is caring for a patient who is to undergo a thoracentesis. In preparation for the procedure, the nurse will position the patient in which of the following positions?
Sitting on the edge of the bed
A client presents to the emergency department with fluid overload. The nurse is concerned about fluid accumulation in the lungs. On which of the following areas would the nurse focus the lung assessment?
Bilateral lower lobes
High or increased compliance occurs in which disease process?
Emphysema
You are caring for a 65-year-old client who has been newly diagnosed with emphysema. The client is confused by the new terms and wants to know what ventilation means. Which of the following can instruct this client?
Ventilation is breathing air in and out of the lungs.
The nurse is assessing the lungs of a patient diagnosed with pulmonary edema. Which of the following would be expected upon auscultation?
Crackles at lung bases
A nurse is reviewing arterial blood gas results on an assigned client. The pH is 7.32 with PCO 2 of 49 mm Hg and a HCO − of 28 mEq/L. The nurse reports to the 3 physician which finding?
Respiratory acidosis
The nursing instructor is talking with senior nursing students about diagnostic procedures used in respiratory diseases. The instructor discusses thoracentesis, defining it as a procedure performed for diagnostic purposes or to aspirate accumulated excess fluid or air from the pleural space. What would the instructor tell the students purulent fluid indicates?
Infection
The nurse is caring for a patient with recurrent hemoptysis who has undergone a bronchoscopy. Immediately following the procedure, the nurse should complete which of the following?
Assess the patient for a cough reflex.
Which of the following clinical manifestations should a nurse monitor for during a pulmonary angiography, which indicates an allergic reaction to the contrast medium?
Difficulty in breathing
A 6-month-old male client and his elder brother, a 3-year- old male, are being seen in the pediatric clinic for their third middle ear infection of the winter. The mother reports they develop an upper respiratory infection and an ear infection seems quick to follow. What contributes to this event?
Eustachian tubes
While conducting the physical examination during assessment of the respiratory system, which of the following conditions does a nurse assess by inspecting and palpating the trachea?
Deviation from the midline
A client experiences a head injury in a motor vehicle accident. The client’s level of consciousness is declining, and respirations have become slow and shallow. When monitoring a client’s respiratory status, which area of the brain would the nurse realize is responsible for the rate and depth?
The pons
You are caring for a client who is in respiratory distress. The physician orders arterial blood gases (ABGs) to determine various factors related to blood oxygenation. What site can ABGs be obtained from?
A puncture at the radial artery
The nurse is calculating the patient’s smoking history in pack-years. The patient has recently been diagnosed with malignant lung cancer. The patient states he has been smoking two packs of cigarettes a day for the past 11 years. The nurse correctly documents the patient’s pack-years as which of the following?
22
Which ventilation-perfusion ratio is exhibited by a pulmonary emboli?
Dead space
Which of the following terms will the nurse use to document the inability of a patient to breathe easily unless positioned upright?
Orthopnea
In relation to the structure of the larynx, the cricoid cartilage is which of the following?
The only complete cartilaginous ring in the larynx
Which respiratory volume is the maximum volume of air that can be inhaled after maximal expiration?
Inspiratory reserve volume
The nurse is completing a physical assessment of a patient’s trachea. The nurse inspects and palpates the trachea for which of the following?
Deviation from the midline
A thoracentesis is performed to obtain a sample of pleural fluid or a biopsy specimen from the pleural wall for diagnostic purposes. What does bloody fluid indicate?
Malignancy
The nurse is caring for a patient who is scheduled for a bronchoscopy. The nurse understands that it is important to provide the required information and appropriate explanations for any diagnostic procedure to a patient with a respiratory disorder in order to do which of the following?
Manage decreased energy levels
Which of the following results in decreased gas exchange in older adults?
The alveolar walls contain fewer capillaries.
Which of the following is a true statement regarding air pressure variances?
Air is drawn through the trachea and bronchi into the alveoli during inspiration.
Which of the following is an age-related change associated with the respiratory system?
Decreased size of the airway
The clinical finding of pink frothy sputum may be an indication of which of the following?
Pulmonary edema
A patient with newly diagnosed emphysema is admitted to the medical-surgical unit for evaluation. Which of the following does the nurse recognize is a deformity of the chest wall that occurs as a result of overinflation of the lungs in this patient population?
Barrel chest
The nurse is caring for a critically ill patient in the ICU). The nurse documents the patient’s respiratory rate as bradypnea. The nurse recognizes bradypnea is associated with which of the following conditions?
Increased intracranial pressure
The nurse is caring for a patient with suspected lung cancer. Which of the following imaging studies is more accurate in detecting malignancies than a CT scan?w
PET scan
The nurse auscultates the lung sounds of a patient during a routine assessment. The sounds produced are harsh and cracking, sounding like two pieces of leather being rubbed together. The nurse would be correct in documenting this finding as which of the following?
Pleural friction rub
The nurse is caring for a patient with extensive respiratory disease. Which of the following is a late sign of hypoxia in the patient?
Cyanosis
The nurse is caring for a patient diagnosed with pneumonia. The nurse will assess the patient for tactile fremitus by completing which of the following?
Asking the patient to repeat “ninety-nine” as the nurse’s hands move down the patient’s thorax
The nurse is caring for a patient with recurrent hemoptysis who has undergone a bronchoscopy. Immediately following the procedure, the nurse should complete which of the following?
Assess the patient for a cough reflex.
The nurse is caring for a patient complaining of chest discomfort. The patient’s admitting diagnosis is left lower lobe pneumonia. Which of the following strategies will the nurse instruct the patient to use to help alleviate the discomfort?
Lying on the right side
A patient presents to the ED complaining of severe coughing episodes. The patient states the “episodes are more intense at night.” The nurse should suspect which of the following conditions based on the patient’s primary complaint?
Left-sided heart failure
The nurse answers the call light of a male patient. The patient is complaining of an irritating tickling sensation in the throat, a salty taste, and a burning sensation in the chest. Upon further assessment, the nurse notes a tissue with bright red, frothy blood at the bedside. The nurse can assume the source of the blood is likely from which of the following?
The lungs
Austin Holbritter, a six-month-old male, and his elder brother Matthew, a three-year-old male, are being seen in the pediatric clinic where you practice nursing. They are being seen by the physician for their third middle ear infection of this winter season. The mother reports they develop an upper respiratory infection and an ear infection seems quick to follow. What contributes to this event?
Eustachian tubes
A client with chronic bronchitis is admitted to the health facility. Auscultation of the lungs reveals low- pitched, rumbling sounds. Which of the following describes these sounds?
Rhonchi
Upon palpation of the sinus area, what would the nurse identify as a normal finding?
No sensation during palpation
The nurse auscultates lung sounds that are harsh and cracking, sounding like two pieces of leather being rubbed together. The nurse would be correct in documenting this finding as
pleural friction rub
The nurse is caring for a client diagnosed with asthma. While performing the shift assessment, the nurse auscultates breath sounds including sibilant wheezes, which are continuous musical sounds. What characteristics describe sibilant wheezes?
They can be heard during inspiration and expiration.
The instructor of the pre-nursing physiology class is explaining respiration to the class. What does the instructor explain is the main function of respiration?
To exchange oxygen and CO2 between the atmospheric air and the blood and between the blood and the cells
A nurse is preparing a client with a pleural effusion for a thoracentesis. The nurse should:
assist the client to a sitting position on the edge of the bed, leaning over the bedside table.
Knowing respiratory physiology is important to understand how the disease process can work within that system. Which hollow tube transports air from the laryngeal pharnyx to the bronchi?
Trachea
The nurse is assessing the lungs of a patient diagnosed with pulmonary edema. Which of the following would be expected upon auscultation?
Crackles at lung bases
In which position should the patient be placed for a thoracentesis?
sitting on the edge of bed
The nurse enters the room of a client who is being monitored with pulse oximetry. Which of the following factors may alter the oximetry results?
Diagnosis of peripheral vascular disease
While auscultating the lungs of a client with asthma, the nurse hears a continuous, high-pitched whistling sound on expiration. The nurse will document this sound as which of the following?
Wheezes
A nonverbal client has just finished undergoing a bronchoscopy procedure and writes that he want to eat lunch now. Which intervention is necessary for the nurse to complete at this time?
Assess for a cough reflex.
Which of the following is an age- related change associated with the lung?
Increased thickness of the alveolar membranes
You are caring for a client who is in respiratory distress. The physician orders arterial blood gases (ABGs) to determine various factors related to blood oxygenation. What site can ABGs be obtained from?
A puncture at the radial artery
A physician has ordered that a client with suspected lung cancer undergo magnetic resonance imaging (MRI). The nurse explains the benefits of this study to the client. Included in teaching would be which of the following regarding the MRI?
MRI can view soft tissues and can help stage cancers.
A son brings his father into the clinic, stating that his father’s color has changed to bluish around the mouth. The father is confused, with a respiratory rate of 28 breaths per minute and scattered crackles throughout. The son states this condition just occurred within the last hour. Which of the following factors indicates that the client’s condition has lasted for more than 1 hour?
Cyanosis
A patient diagnosed with diabetic ketoacidosis would be expected to have which type of respiratory pattern?
Kussmaul respirations
Normally, approximately what percentage of the blood pumped by the right ventricle does not perfuse the alveolar capillaries?
2%
The nurse is admitting a client who just had a bronchoscopy. Which assessment should be the nurse’s priority?
Swallow reflex
The nurse working in the radiology clinic is assisting with a pulmonary angiography. The nurse knows that when monitoring clients after a pulmonary angiography, what should the physician be notified about?
Absent distal pulses
A client appears to be breathing faster than during the last assessment. Which of the following interventions should the nurse perform?
Count the rate of respirations.
A client has a nursing diagnosis of “ineffective airway clearance” as a result of excessive secretions. An appropriate outcome for this client would be which of the following?
Lungs are clear on auscultation.
A nurse enters a client’s room and observes a container with sputum. Upon questioning about the specimen, which of the following items of information from the client would necessitate the nurse to obtain a new specimen?
“I coughed that up about 8 hours ago.”
Which ventilation-perfusion ratio is exhibited by acute respiratory distress syndrome (ARDS)?
Silent Unit
Silent Unit Mr. Sam Wallace, a 53-year-old male, is a regular client in the respiratory group where you practice nursing. As with all adults, millions of alveoli form most of the pulmonary mass. The squamous epithelial cells lining each alveolus consist of different types of cells. Which type of the alveoli cells produce surfactant?
Type II Cells
A patient has an order for arterial blood gases (ABG) to be drawn? Which of the following tests must be done prior to the procedure?
Allen Test
Which of the following is a noninvasive method of continuously monitoring the oxygen saturation of hemoglobin (SaO2)?
Pulse Oximetry
Which of the following is a late sign of hypoxia?
Cyanosis
A nurse is concerned that a client may develop postoperative atelectasis. Which nursing diagnosis would be most appropriate if this complication occurs?
Impaired gas exchange
Which of the following results in decreased gas exchange in older adults?
The alveolar walls contain fewer capillaries.
Perfusion refers to blood supply to the lungs, through which the lungs receive nutrients and oxygen. What are the two methods of perfusion?
The two methods of perfusion are the bronchial and pulmonary circulation
While assessing for tactile fremitus, the nurse palpates almost no vibration. Which of the following conditions in this client’s history will account for this finding?
Emphysema
A new nurse auscultates adventitious breath sounds but is not sure what to document and confers with an experienced nurse. This experienced nurse documents a pleural friction rub. Which of the following did the experienced nurse do during her assessment to identify the rub?
Instructed the client to hold the breath
A student nurse is caring for a client who is severely anemic. The instructor asks the student how anemia affects the transport of oxygen to the cells. What would be the student’s best answer?
“The cells are denied adequate oxygen because most of the oxygen in the body is transported by the hemoglobin in red blood cells.”
A black client with asthma seeks emergency care for acute respiratory distress. Because of this client’s dark skin, the nurse should assess for cyanosis by inspecting the:
mucous membranes.
An 18-month-old child is brought to the Emergency Department by parents who explain that their child swallowed a watch battery. Radiologic studies show that the battery is in the lungs. Which area of lung is the battery most likely to be in?
right upper lung
A 53-year-old client is seeing the physician today because he has had laryngitis for 2 weeks. After a thorough examination, the doctor orders medications and instructs the client to follow up in 1 week if his voice has not improved. What is the primary function of the larynx?
producing sound
A nurse is caring for a client after a lung biopsy. Which assessment finding requires immediate intervention?
Respiratory rate of 44 breaths/minute
Which of the following is an age- related change associated with the respiratory system?
Decreased size of the airway
You are the hospice nurse caring for a client with pulmonary fibrosis who wants to die at home. The client is having difficulty breathing. The family asks why it is so hard for the client to breathe. What would be the nurse’s best response?
The fibrosis of the lungs makes the lungs stiff, which makes it harder to breathe.
A client arrives in the emergency department reporting shortness of breath. She has 3+ pitting edema below the knees, a respiratory rate of 36 breaths per minute, and heaving respirations. The nurse auscultates the client’s lungs to reveal coarse, moist, high-pitched, and non-continuous sounds that do not clear with coughing. The nurse will document these sounds as which type?
Crackles
You are studying for a physiology test about the respiratory system. What should you know about central chemoreceptors in the medulla?
They respond to changes in CO2 levels and hydrogen ion concentrations (pH) in the cerebrospinal fluid.
Which of the following clinical manifestations should a nurse monitor for during a pulmonary angiography, which indicates an allergic reaction to the contrast medium?
Difficulty in breathing
Why is it important for a nurse to provide required information and appropriate explanations of diagnostic procedures to patients with respiratory disorders?
Manage decreased energy levels
A client is chronically short of breath and yet has normal lung ventilation, clear lungs, and an arterial oxygen saturation SaO2 of 96% or better. The client most likely has:
a possible hematologic problem.
A 13-year-old client at the pulmonary clinic where you practice nursing has an extensive history of asthma and is seeing the pulmonologist for her monthly appointment. What are the primary functions of the lungs? Choose all correct options.
- Ventilation
* Gas exchange
On arrival at the intensive care unit, a critically ill client suffers respiratory arrest and is placed on mechanical ventilation. The physician orders pulse oximetry to monitor the client’s arterial oxygen saturation (SaO2) noninvasively. Which vital sign abnormality may alter pulse oximetry values?
hypotension
A student nurse is working with a client who is diagnosed with head trauma. The nurse has documented Cheyne-Stokes respirations. The student would expect to see which of the following?
Regular breathing where the rate and depth increase, then decrease
In a patient diagnosed with increased intracranial pressure (IICP), the nurse would expect to observe which of the following respiratory rate or depth?
Bradypnea
If concern exists about fluid accumulation in a client’s lungs, what area of the lungs will the nurse focus on during assessment?
Bilateral lower lobes
What is the difference between respiration and ventilation?
Ventilation is the movement of air in and out of the respiratory tract.
Which diagnostic is more accurate in detecting malignancies than a CT scan?
PET scan
You are caring for a client admitted with chronic bronchitis. The client is having difficulty breathing, and the family asks you what causes this difficulty. What would be your best response?
“Conditions such as chronic bronchitis cause thickening of the bronchial mucosa so it makes it harder to breathe.
A client with chronic bronchitis is admitted with an exacerbation of symptoms. During the nursing assessment, the nurse will expect which of the following findings? Select all that apply.
- Use of accessory muscles to breathe
* Purulent sputum with frequent coughing
A nurse assesses a client’s respiratory status. Which observation indicates that the client is having difficulty breathing?
Use of accessory muscles
During a pulmonary assessment, the nurse observes the chest for configuration. She identifies the findings as normal. Which of the following would be consistent with normal assessment?
Lateral diameter greater than anteroposterior diameter
Not every structure in the upper airway has a purpose in respiration. There are some structures whose role is immunological. Which of the following structures protect against infection? Choose all correct responses.
- Pharyngeal tonsils
* Palantine tonsils
A nurse is performing a respiratory assessment on a client with pneumonia. She asks the client to say “ninety-nine” several times. Through her stethoscope, she hears the words clearly over his left lower lobe. What term should the nurse use to document this finding?
Bronchophony
The instructor in the anatomy and physiology class is talking about alveolar respiration. What would the instructor tell the class is the main purpose of alveolar respiration?
Determines amount of CO2 in the body
Which of the following is a true statement regarding air pressure variances?
Air is drawn through the trachea and bronchi into the alveoli during inspiration
The nurse auscultates lung sounds that are harsh and cracking, sounding like two pieces of leather being rubbed together. The nurse would be correct in documenting this finding as
pleural friction rub
Upon palpation of the sinus area, what would the nurse identify as a normal finding?
No sensation during palpation
The nurse is admitting a client who just had a bronchoscopy. Which assessment should be the nurse’s priority?
Swallow reflex
A nurse is concerned that a client may develop postoperative atelectasis. Which nursing diagnosis would be most appropriate if this complication occurs?
Impaired gas exchange
A nurse is preparing a client for bronchoscopy. Which instruction should the nurse give to the client?
Don’t eat
In which position should the patient be placed for a thoracentesis?
Sitting on the edge of the bed
The nurse is caring for a client diagnosed with asthma. While performing the shift assessment, the nurse auscultates breath sounds including sibilant wheezes, which are continuous musical sounds. What characteristics describe sibilant wheezes?
They can be heard during inspiration and expiration.
A nurse enters a client’s room and observes a container with sputum. Upon questioning about the specimen, which of the following items of information from the client would necessitate the nurse to obtain a new specimen?
“I coughed that up about 8 hours ago.”
A 53-year-old client sees the physician because he has had laryngitis for 2 weeks. After a thorough examination, the doctor orders medications and instructs the client to follow- up in 1 week if his voice has not improved. What is the primary function of the larynx?
Producing sound
Knowing respiratory physiology is important to understand how the disease process can work within that system. Which hollow tube transports air from the laryngeal pharynx to the bronchi?
Trachea
Which of the following is a deformity of the chest that occurs as a result of over inflation of the lungs?
Barrel chest
A client with chronic bronchitis is admitted to the health facility. Auscultation of the lungs reveals low-pitched, rumbling sounds. Which of the following describes these sounds?
Rhonchi
A client with a respiratory condition is receiving oxygen therapy. While assessing the client’s PaO2, the nurse knows that the therapy has been effective based on which of the following readings?
84 mm Hg
A client is on a ventilator. Alarms are sounding, indicating an increase in peak airway pressure. The nurse assesses first for
A kink in the ventilation tubing
For a client who has a chest tube connected to a closed water-seal drainage system, the nurse should include which action in the care plan?
Measuring and documenting the draining in the collection chamber
A nurse prepares to perform postural drainage. How should the nurse ascertain the best position to facilitate clearing the lungs?
Auscultation
A client is on a positive-pressure ventilator with a synchronized intermittent mandatory ventilation (SIMV) setting. The ventilator is set for 8 breaths per minute. The client is taking 6 breaths per minute independently. The nurse
continues assessing the client’s respiratory status frequently
A nurse is assigned to care for a client with a tracheostomy tube. How can the nurse communicate with this client?
By supplying a magic slate or similar device
Which type of oxygen therapy includes the administration of oxygen at pressure greater than 1 atmosphere?
Hyperbaric
For a client with an endotracheal (ET) tube, which nursing action is the most important?
Auscultating the lungs for bilateral breath sounds
The nurse is assisting a phys with an ET intubation for a client in respiratory failure. It is most important for the nurse to assess for:
symmetry of the client’s chest expansion
A home health nurse is visiting a home care client with advanced lung cancer. Upon assessing the client, the nurse discovers wheezing, bradycardia, and a resp rate of 10 breaths per minute. These signs are associated with which condition?
hypoxia
Positive end-expiratory pressure (PEEP) therapy has which effect on the heart?
Reduced cardiac output
A client with chronic obstructive pulmonary disease (COPD) is intubated and placed on continuous mechanical ventilation. Which equipment is most important for the nurse to keep at this client’s bedside?
Manual Resuscitation bag
Which type of ventilator has a present volume of air to be delivered with each inspiration?
Volume-controlled
The nurse is assisting a client with postural drainage. Which of the following demonstrates correct implementation of this technique?
Instruct the client to remain in each position of the postural drainage sequence for 10-15 minutes
After lobectomy for lung cancer, a client receives a chest tube connected to a disposable chest drainage system. The nurse observes that the drainage system is functioning correctly when she notes tidal movements or fluctuations in which compartment of the system as the client breathes?
Water-sealed chamber
A client is receiving supplemental oxygen. When determining the effectiveness of oxygen therapy, which arterial blood gas value is most important?
Partial pressure of arterial oxygen (PaO2)
The nurse is teaching a postoperative client who had a coronary artery bypass graft about using the incentive spirometer. The nurse instructs the client to perform the exercise in the following order:
Sit in an upright position Place the mouthpiece of the spirometer in the mouth Break air in through the mouth Hold breath for about 3 seconds Exhale air slowly through mouth
Which of the following is the most reliable and accurate method for delivering precise concentrations of oxygen through noninvasive means?
Venturi mask
A client has a sucking stab wound to the chest. Which action should the nurse first?
Apply a wound dressing over the wound and tape it on three sides
A client has been place on a ventilator, and the spouse is visiting for the first time. The spouse begins to cry. The best statement by the nurse is
Tell me about what you are feeling
