Lewis Ch-28: Respiratory System Flashcards
(22 cards)
The nurse is admitting a client with acute shortness of breath. Which of the following actions should the nurse take during the initial assessment of the client?
a. Complete a full physical examination to determine the systemic effect of the respiratory distress.
b. Obtain a comprehensive health hx to determine the extent of any prior respiratory problems.
c. Delay the physical assessment and ask family members about any hx of respiratory problems.
d. Perform a respiratory system assessment and ask specific questions about this episode of respiratory distress.
d. Perform a respiratory system assessment and ask specific questions about this episode of respiratory distress.
The nurse is preparing a client with a right-sided pleural effusion for a thoracentesis. Which of the following positions should the nurse position the client?
a. Supine with the head of the bed elevated 45 degrees
b. In the Trendelenburg position with both arms extended
c. On the left side with the right arm extended above the head
d. Sitting upright with the arms supported on an over bed table
d. Sitting upright with the arms supported on an over bed table
Correct answer: d. Sitting upright with the arms supported on an over-bed table
This is the gold-standard position for thoracentesis because it:
• Opens up the intercostal spaces (more room between ribs = easier needle access)
• Lets gravity pool the fluid downward, so the needle hits the jackpot
• Stabilizes the patient (arms supported = fewer accidental wiggles when you’re inserting a needle next to the lung, which we all appreciate)
The nurse is caring for a client with a metabolic acidosis of unknown origin. Which of the following findings should the nurse expect based on this diagnosis?
a. Intercostal retractions
b. Kussmaul’s respirations
c. Low oxygen saturation
d. Decrease in venous O2 pressure.
b. Kussmaul’s respirations
When someone has metabolic acidosis, their blood becomes too acidic (low pH). That could be from kidney failure, diabetic ketoacidosis (DKA), or honestly just life falling apart internally. The body, in its desperate attempt to fix it, tries to get rid of CO₂ (a form of acid) through the lungs.
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Enter: Kussmaul’s respirations
This is the body going, “Screw elegance, we’re gonna BREATHE BIG.”
• Deep
• Rapid
• Labored
• And basically trying to blow off as much carbon dioxide as possible.
It’s like the body’s idea of CPR for acid-base balance.
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Why not the other options?
• a. Intercostal retractions = sign of airway obstruction or respiratory distress, not acid-base drama.
• c. Low oxygen saturation = more of a hypoxia issue, not the classic metabolic acidosis clue.
• d. Decreased venous O₂ pressure = not specific and definitely not your big giveaway.
The nurse is auscultating a client’s lungs and hears short, high pitched sounds during exhalation in the lower 1/3 of both lungs. Which of the following information should the nurse document?
a. Expiratory crackles at the bases
b. Expiratory wheezes in both lungs
c. Abnormal lung sounds in the bases of both lungs
d. Pleural friction rub in the right and left lower lobes
b. Expiratory wheezes in both lungs
The nurse is palpating the posterior chest of a client while the client says “99” and notes that no vibration is felt. Which of the following information should the nurse document?
a. Diminished expansion
b. Dullness to percussion
c. Absent tactile fremitus
d. Decreased breath sounds
c. Absent tactile fremitus
What is tactile fremitus?
It’s when you feel vibrations on the chest wall as a patient says something like “99.” That sound should travel through the lung tissue and hit your hand like a little phone buzz.
So if it’s absent?
That means:
• Sound/vibration isn’t traveling through the lung.
• Something’s in the way, like fluid, air, or a mass.
Possible causes:
• Pleural effusion (fluid in the pleural space)
• Pneumothorax (air where it shouldn’t be)
• Atelectasis (collapsed lung tissue)
• Or sometimes a thick chest wall if the person is very muscular or has a lot of tissue.
The nurse is caring for a client with a chronic cough who has had a bronchoscopy. Which of the following actions should the nurse include in the nursing care plan after the procedure?
a. Elevate the head of the bed to 80-90 degrees.
b. Keep the client NPO until the gag reflex returns.
c. Place on bed rest for at least 4 hours post bronchoscopy
d. Notify the health care provider about blood-tinged mucus.
b. Keep the client NPO until the gag reflex returns.
After a bronchoscopy, the gag reflex is temporarily suppressed due to the local anesthetic (often lidocaine) used to numb the throat and prevent discomfort during the procedure.
So, when does it return?
The gag reflex typically returns within 1 to 2 hours after the procedure, but this varies depending on the amount of anesthetic used and the individual’s response.
The nurse must assess for the return of the gag reflex before allowing oral intake, to prevent aspiration
The nurse is auscultating a client’s chest while the client takes a deep breath and hears loud, high pitched, “blowing” sounds at both lung bases. Which of the following information should the nurse document?
a. Normal sounds
b. Vesicular sounds
c. Abnormal sounds
d. Adventitious sounds
c. Abnormal sounds
• Bronchial sounds (loud, high-pitched, blowing) are heard over the trachea and large airways.
• Vesicular sounds (soft, low-pitched) are expected over the lung periphery, like the bases.
So when bronchial sounds are heard at the bases, that’s considered abnormal
The nurse is caring for a client with respiratory disease and observes that the client’s SpO2 drops from 92% to 88% while the client is ambulating in the hallway. Which of the following actions should the nurse take next?
a. Notify the health care provider.
b. Document the response to exercise
c. Administer the PRN supplemental O2
d. Encourage the client to pace activity.
c. Administer the PRN supplemental O2
Which of the following actions should the nurse plan to take for a client who is scheduled for pulmonary functions testing (PFT)?
a. Explain reasons for NPO status.
b. Administer sedative drug before PFT.
c. Assess pulse and BP after the procedure.
d. Teach deep inhalation and forceful exhalation.
d. Teach deep inhalation and forceful exhalation.
The nurse is observing a student who is listening to a client’s lungs. Which of the following actions by the student indicates a need to review respiratory assessment skills?
a. The student compares breath sounds from side to side.
b. The student listens only over the posterior part of the chest.
c. The student places the stethoscope over the scapulae and then auscultates.
d. The student starts at the base of the posterior lung and moves to the apices.
c. The student places the stethoscope over the scapulae and then auscultates.
The nurse is reviewing a client’s laboratory results and identifies which of the following values as normal tidal volume?
a. 100 mL
b. 250 mL
c. 500 mL
d. 1000 mL
c. 500 mL
The normal tidal volume—the amount of air you breathe in or out during a regular, quiet breath—is about 500 mL in a healthy adult.
The nurse is admitting a client to the emergency department who has sudden onset shortness of breath and has diagnosed with a possible pulmonary embolus. To confirm the diagnosis, which of the following diagnostic measures should the nurse anticipate?
a. Positron emission tomography (PET) scan
b. Chest x-ray
c. Bronchoscopy
d. Spiral computed tomography (CT) scan
d. Spiral computed tomography (CT) scan
- Which of the following lung structures has the most generations?
a. Segmental bronchi
b. Subsegmental bronchi
c. Bronchioles
d. Alveoli
d. Alveoli
Which of the following pH values is abnormal for a pH when assessing blood results of a mixed venous blood sample?
a. 7.31
b. 7.35
c. 7.40
d. 7.42
d. 7.42
Normal venous 7.31-7.41
Normal Arterial 7.35-7.45
The nurse is analyzing the results of a client’s arterial blood gases (ABGs). Which of the following findings require the most immediate action?
a. The arterial oxygen saturation (SaO2) is 92%
b. The partial pressure of oxygen in arterial blood (PaO2) is 59 mm Hg.
c. The partial pressure of CO2 in arterial blood (PaCO2) is 31 mm Hg.
d. The bicarbonate level (HCO3) is 29 mmol/L
b. The partial pressure of oxygen in arterial blood (PaO2) is 59 mm Hg.
The nurse is assessing the respiratory system of an older-adult client. Which of the following findings indicates that the nurse should take immediate action?
a. The chest appears barrel shaped
b. The client has a weak cough effort
c. crackles are heard from the lung bases to the midline.
d. Hyper-resonance is present across both sides of the chest.
c. crackles are heard from the lung bases to the midline.
The nurse is admitting a client who is hypothermic with an O₂ saturation of 96%. Which of the following actions should the nurse take next?
a. Initiate rewarming of the client
b. Complete a head-to-toe assessment.
c. Obtain arterial blood gases (ABGs)
d. Place the client on high-flow oxygen
d. Place the client on high-flow oxygen
After the nurse has received change-of-shift report, which of the following clients should be assessed first?
a. A client with pneumonia who has crackles in the right lung base.
b. A client with chronic obstructive pulmonary disease (COPD) and pulmonary function testing (PFT) that indicates low forced vital capacity.
c. A client with possible lung cancer who has just returned after bronchoscopy
d. A client with hemoptysis and a 16-mm induration with tuberculin skin testing.
c. A client with possible lung cancer who has just returned after bronchoscopy
The nurse has just received arterial blood gas (ABG) results on four clients. Which of the following results is considered normal?
a. pH 7.32, PaO₂ 85 mm Hg, PaCO₂ 55 mm Hg, and O₂ saturation 90%
b. pH 7.38, PaO₂ 75 mm hg, PaCO₂ 40 mm Hg, and O₂ saturation of 92%
c. pH 7.42, PaO₂ 80 mm Hg, PaCO₂ 33 mm Hg, and O₂ saturation 98%
d. pH 7.52, PaO₂ 90 mm Hg, PaCO₂ 30 mm Hg, and O₂ saturation 94%
b. pH 7.38, PaO₂ 75 mm hg, PaCO₂ 40 mm Hg, and O₂ saturation of 92%
The nurse is assessing a client with chronic obstructive pulmonary disease (COPD) with increasing dyspnea over the last 3 days. Which of the following findings is most important to report to the health care provider?
a. Respirations are 35 bpm
b. Anterior-posterior chest ratio is 1:1
c. Lung expansion is decreased bilaterally.
d. Hyper-resonance to percussion is present
a. Respirations are 35 bpm
The nurse is performing an assessment of the client’s respiratory system. Which of the following parameters is the nurse assessing when using the following illustrated technique?
a. Bronchoscopy
b. Chest expansion
c. Accessory muscle use
d. Diaphragmatic excursion
b. Chest expansion
Which of the following respiratory assessments is normal?
a. Respirations 23 breaths/minute
b. Outward movement of abdomen during inspiration
c. Increase in vibrations with tactile fremitus
d. Tripod position
b. Outward movement of abdomen during inspiration
