Download TB med surgical chapter 20 and more Study notes Nursing in PDF only on Docsity!
Chapter 20: Assessment of Respiratory Function
- A patient is having her tonsils removed. The patient 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. Ans: B Feedback: 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 patient who has just returned to the unit after a colon resection. The patient is showing signs of hypoxia. The nurse knows that this is probably caused by what? A) Nitrogen narcosis B) Infection C) Impaired diffusion D) Shunting Ans: D Feedback: 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 patient 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 patients tongue and mouth. D) Assess the patients nutritional status. Ans: B Feedback: 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 patients tongue, mouth, and nutrition is not directly relevant to the problem of aspiration.
- The ED nurse is assessing a patient complaining of dyspnea. The nurse auscultates the patients chest and hears wheezing throughout the lung fields. What might this indicate? A) The patient has a narrowed airway. B) The patient has pneumonia. C) The patient needs physiotherapy. D) The patient has a hemothorax. Ans: A Feedback: Wheezing is a high-pitched, musical sound that is often the major finding in a patient with bronchoconstriction or airway narrowing. Wheezing is not normally indicative of pneumonia or hemothorax. Wheezing does not indicate the need for physiotherapy.
- The nurse is caring for a patient admitted with an acute exacerbation of chronic obstructive pulmonary disease. During assessment, the nurse finds that the patient is experiencing increased dyspnea. What is the most accurate measurement of the concentration of oxygen in the patients blood? A) A capillary blood sample B) Pulse oximetry
D) Residual volume Ans: C Feedback: 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 patients arterial oxygen saturation (SaO 2 ). What procedure will best accomplish this? A) Incentive spirometry B) Arterial blood gas (ABG) measurement C) Peak flow measurement D) Pulse oximetry Ans: D Feedback: 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 patient no discomfort. An incentive spirometer is used to assist the patient with deep breathing after surgery. ABG measurement can measure SaO2, but this is an invasive procedure that can be painful. Some patients with asthma use peak flow meters to measure levels of expired air.
- A patient asks the nurse why an infection in his upper respiratory system is affecting the clarity of his speech. Which structure serves as the patients resonating chamber in speech? A) Trachea B) Pharynx C) Paranasal sinuses D) Larynx Ans: C
Feedback: 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 tubelike 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 patient with a decreased level of consciousness is in a recumbent position. How should the nurse best assess the lung fields for a patient in this position? A) Inform that physician that the patient is in a recumbent position and anticipate an order for a portable chest x-ray. B) Turn the patient to enable assessment of all the patients lung fields. C) Avoid turning the patient, and assess the accessible breath sounds from the anterior chest wall. D) Obtain a pulse oximetry reading, and, if the reading is low, reposition the patient and auscultate breath sounds. Ans: B Feedback: Assessment of the anterior and posterior lung fields is part of the nurses routine evaluation. If the patient is recumbent, it is essential to turn the patient 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. This makes the other given options unacceptable.
- A patient is undergoing testing to see if he has a pleural effusion. Which of the nurses respiratory assessment findings would be most consistent with this diagnosis? A) Increased tactile fremitus, egophony, and a dull sound upon percussion of the chest wall B) Decreased tactile fremitus, wheezing, and a hyperresonant sound upon percussion of the chest wall C) Lung fields dull to percussion, absent breath sounds, and a pleural friction rub D) Normal tactile fremitus, decreased breath sounds, and a resonant sound upon percussion of the chest wall Ans: C
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) Ans: A Feedback: High or increased compliance occurs if the lungs have lost their elasticity and the thorax is overdistended, in conditions such as emphysema. Conditions associated with decreased compliance include pneumothorax, hemothorax, pleural effusion, pulmonary edema, atelectasis, pulmonary fibrosis, and ARDS.
- A medical nurse has admitted a patient to the unit with a diagnosis of failure to thrive. The patient 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 patients physician because these symptoms are suggestive of what? A) Pneumothorax B) Lung tumors C) Infection D) Pulmonary edema Ans: C Feedback: 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 patient 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 Ans: D Feedback: 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 patient 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 Ans: D Feedback: Vital capacity is measured by having the patient 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 patients 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
C) Whispered pectoriloquy D) Sonorous wheezes Ans: B Feedback: This finding would be documented as egophony, which can be best assessed by instructing the patient 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 patient who has been diagnosed with emphysema and who has just had a pulmonary function test (PFT) ordered. The patient asks, What exactly is this test for? What would be the nurses 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. Ans: A Feedback: PFTs are routinely used in patients 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 patient is being treated for a pulmonary embolism and the medical nurse is aware that the patient suffered an acute disturbance in pulmonary perfusion. This involved an alteration in what 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. Ans: D Feedback: 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 patient and is attempting to distinguish between vesicular, bronchovesicular, and bronchial (tubular) breath sounds. The nurse should distinguish between these normal breath sounds on what basis? 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 Ans: A Feedback: 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. Normal breath sounds are heard on both inspiration and expiration, and are continuous. They are not distinguished solely on the basis of volume.
- A patient 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) Acidbase balance B) Perfusion C) Diffusion D) Ventilation Ans: B
close the bronchial tree. An infection does not cause necrosis of lung tissues.
- The nurse is performing a respiratory assessment of a patient who has been experiencing episodes of hypoxia. The nurse is aware that this is ultimately attributable to impaired gas exchange. On what factor does adequate gas exchange primarily depend? A) An appropriate perfusiondiffusion ratio B) An adequate ventilationperfusion ratio C) Adequate diffusion of gas in shunted blood D) Appropriate blood nitrogen concentration Ans: B Feedback: Adequate gas exchange depends on an adequate ventilationperfusion ratio. There is no perfusiondiffusion ratio. Adequate gas exchange does not depend on the diffusion of gas in shunted blood or a particular concentration of nitrogen.
- The nurse is caring for a patient with lung metastases who just underwent a mediastinotomy. What should be the focus of the nurses postprocedure care? A) Assisting with pulmonary function testing (PFT) B) Maintaining the patients chest tube C) Administering oral suction as needed D) Performing chest physiotherapy Ans: B Feedback: Chest tube drainage is required after mediastinotomy. PFT, chest physiotherapy, and oral suctioning would all be contraindicated because of the patients unstable health status.
- The nurse is caring for a patient who has a pleural effusion and who underwent a thoracoscopic procedure earlier in the morning. The nurse should prioritize assessment for which of the following? A) Sputum production
B) Shortness of breath C) Throat discomfort D) Epistaxis Ans: B Feedback: Follow-up care in the health care facility and at home involves monitoring the patient for shortness of breath (which might indicate a pneumothorax). All of the listed options are relevant assessment findings, but shortness of breath is the most serious complication.
- A gerontologic nurse is analyzing the data from a patients focused respiratory assessment. The nurse is aware that the amount of respiratory dead space increases with age. What is the effect of this physiological change? A) Increased diffusion of gases B) Decreased diffusion capacity for oxygen C) Decreased shunting of blood D) Increased ventilation Ans: B Feedback: The amount of respiratory dead space increases with age. Combined with other changes, this results in a decreased diffusion capacity for oxygen with increasing age, producing lower oxygen levels in the arterial circulation. Decreased shunting and increased ventilation do not occur with age.
- The nurse is assessing the respiratory status of a patient who is experiencing an exacerbation of her emphysema symptoms. When preparing to auscultate, what breath sounds should the nurse anticipate? A) Absence of breath sounds B) Wheezing with discontinuous breath sounds C) Faint breath sounds with prolonged expiration D) Faint breath sounds with fine crackles
- The ED nurse is assessing the respiratory function of a teenage girl who presented with acute shortness of breath. Auscultation reveals continuous wheezes during inspiration and expiration. This finding is most suggestive what? A) Pleurisy B) Emphysema C) Asthma D) Pneumonia Ans: C Feedback: Sibilant wheezes are commonly associated with asthma. They do not normally accompany pleurisy, emphysema, or pneumonia.
- The nurse is caring for a patient who has been scheduled for a bronchoscopy. How should the nurse prepare the patient for this procedure? A) Administer a bolus of IV fluids. B) Arrange for the insertion of a peripherally inserted central catheter. C) Administer nebulized bronchodilators every 2 hours until the test. D) Withhold food and fluids for several hours before the test. Ans: D Feedback: Food and fluids are withheld for 4 to 8 hours before the test to reduce the risk of aspiration when the cough reflex is blocked by anesthesia. IV fluids, bronchodilators, and a central line are unnecessary.
- A nurse educator is reviewing the implications of the oxyhemoglobin dissociation curve with regard to the case of a current patient. The patient currently has normal hemoglobin levels, but significantly decreased SaO 2 and PaO 2 levels. What is an implication of this physiological state? A) The patients tissue demands may be met, but she will be unable to respond to physiological stressors.
B) The patients short-term oxygen needs will be met, but she will be unable to expel sufficient CO 2. C) The patient will experience tissue hypoxia with no sensation of shortness of breath or labored breathing. D) The patient will experience respiratory alkalosis with no ability to compensate. Ans: A Feedback: With a normal hemoglobin level of 15 mg/dL and a PaO 2 level of 40 mm Hg (SaO 2 75%), there is adequate oxygen available for the tissues, but no reserve for physiological stresses that increase tissue oxygen demand. If a serious incident occurs (e.g., bronchospasm, aspiration, hypotension, or cardiac dysrhythmias) that reduces the intake of oxygen from the lungs, tissue hypoxia results.
- A medical patient rings her call bell and expresses alarm to the nurse, stating, Ive just coughed up this blood. That cant be good, can it? How can the nurse best determine whether the source of the blood was the patients lungs? A) Obtain a sample and test the pH of the blood, if possible. B) Try to see if the blood is frothy or mixed with mucus. C) Perform oral suctioning to see if blood is obtained. D) Swab the back of the patients throat to see if blood is present. Ans: B Feedback: Though not definitive, blood from the lung is usually bright red, frothy, and mixed with sputum. Testing the pH of nonarterial blood samples is not common practice and would not provide important data. Similarly, oral suctioning and swabbing the patients mouth would not reveal the source.
- The nurse is completing a patients health history with regard to potential risk factors for lung disease. What interview question addresses the most significant risk factor for respiratory diseases? A) Have you ever been employed in a factory, smelter, or mill? B) Does anyone in your family have any form of lung disease? C) Do you currently smoke, or have you ever smoked?
Asthma is a respiratory illness that has genetic factors. Sleep apnea, pneumonia, and pulmonary edema lack genetic risk factors.
