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52 Cards in this Set
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When assessing a patient's sleep-rest pattern related to respiratory health, what should the nurse ask the patient about (select all that apply)? Have trouble falling asleep? Need to urinate during the night? Awaken abruptly during the night? Sleep more than 8 hours per night? Need to sleep with the head elevated? |
1, 3, 5 The patient with sleep apnea may have insomnia and/or abrupt awakenings. Patients with cardiovascular disease (e.g., heart failure that may affect respiratory health) may need to sleep with the head elevated on several pillows (orthopnea). Sleeping more than 8 hours per night or needing to urinate during the night is not indicative of impaired respiratory health. |
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What should the nurse inspect when assessing a patient with shortness of breath for evidence of long-standing hypoxemia? Chest excursion Spinal curvatures Respiratory pattern Fingernails and their base |
4 Clubbing, a sign of long-standing hypoxemia, is evidenced by an increase in the angle between the base of the nail and the fingernail to 180 degrees or more, usually accompanied by an increase in the depth, bulk, and sponginess of the end of the finger. |
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The nurse is caring for a patient with chronic obstructive pulmonary disorder (COPD) and pneumonia who has an order for arterial blood gases to be drawn. What is the minimum length of time the nurse should plan to hold pressure on the puncture site? 2 minutes 5 minutes 10 minutes 15 minutes |
2 (5 minutes) After obtaining blood for an arterial blood gas measurement, the nurse should hold pressure on the puncture site for 5 minutes by the clock to be sure that bleeding has stopped. An artery is an elastic vessel under much higher pressure than veins, and significant blood loss or hematoma formation could occur if the time is insufficient. |
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A patient with a recent history of a dry cough has had a chest x-ray that revealed the presence of nodules. In an effort to determine whether the nodules are malignant or benign, what is the primary care provider likely to order? Thoracentesis Pulmonary angiogram CT scan of the patient's chest Positron emission tomography (PET) |
4 PET is used to distinguish benign and malignant pulmonary nodules. Because malignant lung cells have an increased uptake of glucose, the PET scan (which uses an IV radioactive glucose preparation) can demonstrate increased uptake of glucose in malignant lung cells. This differentiation cannot be made using CT, a pulmonary angiogram, or thoracentesis. |
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A patient with recurrent shortness of breath has just had a bronchoscopy. What is a priority nursing action immediately following the procedure? Monitor the patient for laryngeal edema. Assess the patient's level of consciousness. Monitor and manage the patient's level of pain. Assess the patient's heart rate and blood pressure. |
1 Priorities for assessment are the patient's airway and breathing, both of which may be compromised after bronchoscopy by laryngeal edema. These assessment parameters supersede the importance of loss of consciousness (LOC), pain, heart rate, and blood pressure, although the nurse should also be assessing these. |
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After assisting at the bedside with a thoracentesis, the nurse should continue to assess the patient for signs and symptoms of what? Bronchospasm Pneumothorax Pulmonary edema Respiratory acidosis |
2 Because thoracentesis involves the introduction of a catheter into the pleural space, there is a risk of pneumothorax. Thoracentesis does not carry a significant potential for causing bronchospasm, pulmonary edema, or respiratory acidosis. |
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The patient had abdominal surgery yesterday. Today the lung sounds in the lower lobes have decreased. The nurse knows this could be due to what occurring? Pain Atelectasis Pneumonia Pleural effusion |
2 Postoperatively there is an increased risk for atelectasis from anesthesia as well as restricted breathing from pain. Without deep breathing to stretch the alveoli, surfactant secretion to hold the alveoli open is not promoted. Pneumonia will occur later after surgery. Pleural effusion occurs because of blockage of lymphatic drainage or an imbalance between intravascular and oncotic fluid pressures, which is not expected in this case. |
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The patient's arterial blood gas results show the PaO2 at 65 mmHg and the SaO2 at 80%. What early manifestations should the nurse expect to observe in this patient? Restlessness, tachypnea, tachycardia, and diaphoresis Unexplained confusion, dyspnea at rest, hypotension, and diaphoresis Combativeness, retractions with breathing, cyanosis, and decreased output Coma, accessory muscle use, cool and clammy skin, and unexplained fatigue |
1 With inadequate oxygenation, early manifestations include restlessness, tachypnea, tachycardia, and diaphoresis, decreased urinary output, and unexplained fatigue. The unexplained confusion, dyspnea at rest, hypotension, and diaphoresis; combativeness, retractions with breathing, cyanosis, and decreased urinary output; coma, accessory muscle use, cool and clammy skin, and unexplained fatigue occur as later manifestations of inadequate oxygenation. |
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When the patient is experiencing metabolic acidosis secondary to type 1 diabetes mellitus, what physiologic response should the nurse expect to assess in the patient? Vomiting Increased urination Decreased heart rate Rapid respiratory rate |
4 When a patient with type 1 diabetes has hyperglycemia and ketonemia causing metabolic acidosis, the physiologic response is to increase the respiratory rate and tidal volume to blow off the excess CO2. Vomiting and increased urination may occur with hyperglycemia, but not as physiologic responses to metabolic acidosis. The heart rate will increase. |
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After swallowing, a 73-year-old patient is coughing and has a wet voice. What changes of aging could be contributing to this abnormality? Decreased response to hypercapnia Decreased number of functional alveoli Increased calcification of costal cartilage Decreased respiratory defense mechanisms |
4 These manifestations are associated with aspiration, which more easily occur in the right lung as the right mainstem bronchus is shorter, wider, and straighter than the left mainstem bronchus. Aspiration occurs more easily in the older patient related to decreased respiratory defense mechanisms (e.g., decreases in immunity, ciliary function, cough force, sensation in pharynx). Changes of aging include a decreased response to hypercapnia, decreased number of functional alveoli, and increased calcification of costal cartilage, but these do not increase the risk of aspiration. |
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The patient is hospitalized with pneumonia. Which diagnostic test should be used to measure the efficiency of gas transfer in the lung and tissue oxygenation? Thoracentesis Bronchoscopy Arterial blood gases Pulmonary function tests |
3 Arterial blood gases are used to assess the efficiency of gas transfer in the lung and tissue oxygenation as is pulse oximetry. Thoracentesis is used to obtain specimens for diagnostic evaluation, remove pleural fluid, or instill medication into the pleural space. Bronchoscopy is used for diagnostic purposes, to obtain biopsy specimens, and to assess changes resulting from treatment. Pulmonary function tests measure lung volumes and airflow to diagnose pulmonary disease, monitor disease progression, evaluate disability, and evaluate response to bronchodilators. |
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The patient is calling the clinic with a cough. What assessment should be made first before the nurse advises the patient? Cough sound, sputum production, pattern Frequency, a family history, hematemesis Smoking, medications, residence location Weight loss, activity tolerance, orthopnea |
1 The sound of the cough, sputum production and description, as well as pattern of the cough's occurrence (including acute or chronic) and what its occurrence is related to are the first assessments to be made to determine the severity. Frequency of the cough will not provide a lot of information. Family history can help to determine a genetic cause of the cough. Hematemesis is vomiting blood and not as important as hemoptysis. Smoking is an important risk factor for COPD and lung cancer and may cause a cough. Medications may or may not contribute to a cough as does residence location. Weight loss, activity intolerance, and orthopnea may be related to respiratory or cardiac problems, but are not as important when dealing with a cough. |
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. During the assessment in the ED, the nurse is palpating the patient's chest. Which finding is a medical emergency? Trachea moved to the left Increased tactile fremitus Decreased tactile fremitus Diminished chest movement |
1 Tracheal deviation is a medical emergency when it is caused by a tension pneumothorax. Tactile fremitus increases with pneumonia or pulmonary edema and decreases in pleural effusion or lung hyperinflation. Diminished chest movement occurs with barrel chest, restrictive disease, and neuromuscular disease. |
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The patient with Parkinson's disease has a pulse oximetry reading of 72%, but he is not displaying any other signs of decreased oxygenation. What is most likely contributing to his low SpO2 level? Motion Anemia Dark skin color Thick acrylic nails |
1 Motion is the most likely cause of the low SpO2 for this patient with Parkinson's disease. Anemia, dark skin color, and thick acrylic nails as well as low perfusion, bright fluorescent lights, and intravascular dyes may also cause an inaccurate pulse oximetry result. There is no mention of these or reason to suspect these in this question. |
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In assessment of the patient with acute respiratory distress, what should the nurse expect to observe (select all that apply)? Cyanosis Tripod position Kussmaul respirations Accessory muscle use Increased AP diameter |
2, 4 Tripod position and accessory muscle use indicate moderate to severe respiratory distress. Cyanosis may be related to anemia, decreased oxygen transfer in the lungs, or decreased cardiac output. Therefore it is a nonspecific and unreliable indicator of only respiratory distress. Kussmaul respirations occur when the patient is in metabolic acidosis to increase CO2 excretion. Increased AP diameter occurs with lung hyperinflation from COPD, cystic fibrosis, or with advanced age. |
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Which patient is exhibiting an early clinical manifestation of hypoxemia? A 48-year-old patient who is intoxicated and acutely disoriented to time and place A 72-year-old patient who has four new premature ventricular contractions per minute A 67-year-old patient who has dyspnea while resting in the bed or in a reclining chair A 94-year-old patient who has renal insufficiency, anemia, and decreased urine output |
2 Early clinical manifestations of hypoxemia include dysrhythmias (e.g., premature ventricular contractions), unexplained decreased level of consciousness (e.g., disorientation), dyspnea on exertion, and unexplained decreased urine output. |
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The nurse is obtaining a focused respiratory assessment of a 44-year-old female patient who is in severe respiratory distress 2 days after abdominal surgery. What is most important for the nurse to assess? Auscultation of bilateral breath sounds Percussion of anterior and posterior chest wall Palpation of the chest bilaterally for tactile fremitus Inspection for anterior and posterior chest expansion |
1 Important assessments obtained during a focused respiratory assessment include auscultation of lung (breath) sounds. Assessment of tactile fremitus has limited value in acute respiratory distress. It is not necessary to assess for both anterior and posterior chest expansion. Percussion of the chest wall is not essential in a focused respiratory assessment. |
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A 67-year-old male patient had a right total knee replacement 2 days ago. Upon auscultation of the patient’s posterior chest, the nurse detects discontinuous, high-pitched breath sounds just before the end of inspiration in the lower portion of both lungs. Which statement most appropriately reflects how the nurse should document the breath sounds? “Bibasilar rhonchi present on inspiration.” “Diminished breath sounds in the bases of both lungs.” “Fine crackles posterior right and left lower lung fields.” “Expiratory wheezing scattered throughout the lung fields.” |
3 Fine crackles are described as a series of short-duration, discontinuous, high-pitched sounds heard just before the end of inspiration. |
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A frail 82-year-old female patient develops sudden shortness of breath while sitting in a chair. What location on the chest should the nurse begin auscultation of the lung fields? Bases of the posterior chest area Apices of the posterior lung fields Anterior chest area above the breasts Midaxillary on the left side of the chest |
1 Baseline data with the most information is best obtained by auscultation of the posterior chest, especially in female patients because of breast tissue interfering with the assessment or if the patient may tire easily (e.g., shortness of breath, dyspnea, weakness, fatigue). Usually auscultation proceeds from the lung apices to the bases unless it is possible the patient will tire easily. In this case the nurse should start at the bases. |
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The nurse is interpreting a tuberculin skin test (TST) for a 58-year-old female patient with end-stage kidney disease secondary to diabetes mellitus. Which finding would indicate a positive reaction? Acid-fast bacilli cultured at the injection site 15-mm area of redness at the TST injection site 11-mm area of induration at the TST injection site Wheal formed immediately after intradermal injection |
3 An area of induration ≥ 10 mm would be a positive reaction in a person with end-stage kidney disease. Reddened, flat areas do not indicate a positive reaction. A wheal appears when the TST is administered that indicates correct administration of the intradermal antigen. Presence of acid-fast bacilli in the sputum indicates active tuberculosis. |
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The primary purpose of the respiratory system is? |
gas exchange |
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gas exchange involves? |
transfer of oxygen and carbon dioxide between the atmosphere and the blood. |
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The upper respiratory tract includes the ? |
nose, mouth, pharynx, adenoids, tonsils, epiglottis, larynx, and trachea. |
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warms, cleanses, and humidifies air before it enters lungs? |
nose |
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The lower respiratory tract consists of the? |
bronchi, bronchioles, alveolar ducts, and alveoli. |
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Gas exchange takes place in the? |
alveoli |
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The upper respiratory tract and the bronchi/bronchioles are passages that conduct air to the alveoli. These passages are called? |
anatomic dead space |
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a lipoprotein that helps to keep the alveoli open, thus preventing alveolar collapse? |
surfactant |
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Contraction of the diaphragm, the major muscle of respiration, results in decreased intrathoracic pressure, allowing? |
allowing air to enter the lungs.
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involves inspiration (movement of air into the lungs) and expiration (movement of air out of the lungs). ??? |
Ventilation |
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an active process, involving muscle contraction? |
inspiration |
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a passive process. When elastic recoil is reduced, expiration becomes a more active, labored process? |
expiration |
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In adults a normal tidal volume (Vt), or volume of air exchanged with each breath, is about? |
500 ml |
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When compliance, or a measure of the ease of lung expansion, is decreased, the lungs are more difficult to ? |
inflate "stiff lungs" |
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arterial blood gases are measured to determine? |
oxygenation status and acid-base balance. ABG analysis includes measurement of the PaO2, PaCO2, acidity (pH), and bicarbonate (HCO3–) in arterial blood. |
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Arterial oxygen saturation can be monitored continuously using a? |
pulse oximetry probe |
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CO2 monitoring can be done using transcutaneous carbon dioxide (PTCCO2) and ? |
end-tidal CO2 (PETCO2) (capnography). |
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Capnography is usually presented as a graph of? |
expiratory CO2 plotted against time. |
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The respiratory center in the ____________ in the _________________ ? responds to chemical and mechanical signals from the body. |
medulla
brainstem |
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a receptor that responds to a change in the chemical composition (PaCO2 and pH) of the fluid around it? |
chemoreceptor |
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stimulated by a variety of physiologic factors, such as irritants, muscle stretching, and alveolar wall distortion? |
mechanical receptors |
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The respiratory defense mechanisms include filtration of?
(5) |
air, the mucociliary clearance system, the cough reflex, reflex bronchoconstriction, and alveolar macrophages. |
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Age-related changes in the respiratory system can be divided into alterations in? (3) |
structure, defense mechanisms, and respiratory control. |
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A cough should be evaluated by the quality of the? |
cough and sputum |
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When listening to the lung sounds, there are three normal breath sounds: |
vesicular, bronchovesicular, and bronchial. |
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sounds are abnormal and include crackles, rhonchi, wheezes, and pleural friction rub? |
adventitious |
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tudies are examined to identify infecting organisms or to confirm a diagnosis? |
sputum |
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most commonly used test for assessment of the respiratory system, as well as the progression of disease and response to treatment.? |
chest x ray |
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a procedure in which the bronchi are visualized through a fiberoptic tube. It may be used for diagnostic purposes to obtain biopsy specimens and assess changes resulting from treatment? |
bronchoscopy |
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insertion of a large bore needle through the chest wall into the pleural space to obtain specimens for diagnostic evaluation, remove pleural fluid, or instill medication into the pleural space. |
thoracentesis |
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measure lung volumes and airflow? |
PFT's...... pulmonary function tests |
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used in diagnosis, measuring functional capacity and response to treatment, and determining level of activity tolerance? |
exercise testing |
