General respiratory and terms to know

Question 1

Which of the following are expected findings of a lung assessment?

A. Relaxed, silent, regular, automatic
B. Regular, grade 2+, manual
C. Relaxed, easily heard, regular, automatic

Answer 1

A. Relaxed, silent, regular, automatic

Question 2

A nurse preforms percussion on a patient with emphysema. What is an expected finding?

A. Resonance
B. Hyporesonance
C. Hyperresonance

Answer 2

C. Hyperresonance

Question 3

How many breaths per minute is expected?

A. 11-21 breaths
B. 5-10 breths
C. 10-20 breaths

Answer 3

C. 10-20 breaths

Question 4

What is the expected range for oxygen saturation?

A. 95-100%
B. 99-100%
C. 85-100%

Answer 4

A. 95-100%

Question 5

Where is the apex of the lung located?

Answer 5

Highest point of lung tissue located above the clavicle

Question 6

How many lobes are in the right side of the lung?

Answer 6

3 lobes

Question 7

How many lobes are in the left side of the lung?

Answer 7

2 lobes

Question 8

What is the innermost layer of the lungs?

Answer 8

Visceral membrane

Question 9

What are the two stages of respiration?

Answer 9

Inspiration and expiration

Question 10

How is breathing controlled?

Where does the body regulate and control breathing?

Answer 10

Breathing is involuntary and controlled by the respiration center in brain stem (pons and medulla).

Question 11

What does ventilation mean?

Answer 11

Ventilation is the action of inspiration and expiration (full cycle)

Question 12

What is Perfusion?

Answer 12

Perfusion is the ability of the cardiovascular system to pump oxygenated blood to the tissues.

Diffusion is responsible for moving the respiratory gases from one area to another by concentraion gradents.

• exchange of gases between air in the alveoli and blood in the capillaries

Google: Blood flowing through the pulmonary capillaries in the lungs
- The amount of blood reaching the alevoli where gas exchange occurs

Question 14

What are some factors of oxygenation?

Answer 14

psychological
decreased oxygen-carring capacity
hypovolemia
decreased inspired oxygen concentration
increased metabolic rate
conditions affecting chest wall movment
developmental
lifestyle
environment

Hypovolemia: a decreased volume of circulating blood in the body

Question 15

What subjective data is related to pulmonary disease?

Answer 15

Persistant cough
Sputum streaked with blood
Voice change
Chest pain (pulmonary embolism can mimic heart attack pain)
SOB
Orthopnea
Dyspnea
Activity intolerance
Recurring pneumonia or bronchitis (3 episodes, longer than 3 months)

Question 16

What subjective data is related to tuberculosis?

Answer 16

Persistent cough
Hemoptysis
Unexplained weight loss
Night sweats
Fever

Question 17

Define orthopnea

Answer 17

Shortness of breath when lying down

Question 18

Define Dyspnea

Answer 18

Shortness of breath

Question 19

Define hemoptysis

Answer 19

Bloody sputum

Question 20

Define tachypnea

Answer 20

RR greater than 24 and shallow

Question 21

Define Hyperventilation

Answer 21

Respiratory rate greater than 24 and deep

Question 22

Define bradypnea

Answer 22

Respiratory rate less than 10

Question 23

Define hypoventilation

Answer 23

Respiratory rate less than 10. Irregular and shallow

Question 24

Define Cheyne-stokes respiration

Answer 24

Wax and wean with apnea (regular)

Question 25

Define biot respiration

Answer 25

wax and wean with apnea (irregular)

Question 26

Describe COPD respiration

Answer 26

Prolonged expiration with dyspneic episodes ## Footnote pursed lip breathing

Question 27

Define tactile freitus

Answer 27

Palpable vibrations ## Footnote Felt when client says "99" Consolidation, mass or fluid

Question 28

What subjective data could be found when assessing risk for lung disease

Answer 28

smoking/ second hand smoke environmental- pollutants, radiation family history of cancer, allergies, COPD, TB Immunocompromised (fungal pneumonia) Lack of immunization (prone to airborne illnesses)

Question 29

What subjective data could be found when assessing for risk of TB

Answer 29

HIV Substance abuse Low income Nursing or group home Homeless Prison Family with TB (community) Immigrant from a country where TB is prevalent

Question 30

General inspection during respiratory assessment | Facial

Answer 30

Facial expression and level of conciousness - hypoxia - air hunger

Question 31

General inspection of respiratory | Thorax

Answer 31

Shape and configuration of thorax - Costal angle 90 degrees - skeltal deformaties

Question 32

General inspection of respiratory | Postion

Answer 32

Position - relaxed able to support own weight without leans on arms ## Footnote This is called tripod positioning

Question 33

General inspection of respiration | Skin and nail

Answer 33

Consistent with genetic background and sun exposure - note abnormal changes of skin, lips, and nails (cyanosis, pallor), lesions or deformaties - the person has to hypoxic to present with cyanosis

Question 34

Where is central cyanosis

Answer 34

Seen on legs first and usually creeps up ## Footnote Appears with honeycomb pattern and blue color

Question 35

What is the rule of thumb when assessing COPD and barrel chest?

Answer 35

Not all patients with COPD have a barrel chest, but all patients with a barrel chest have COPD

Question 36

How do tracheal sounds present?

Answer 36

High pitched, loud These are normal bronchial sounds

Question 37

Where do intercostal reatractions occur?

Answer 37

Above clavicle and sternum Could suggest atelectasis or forced inspiration with COPD