Nursing Assessment: Respiratory System Exam 2

Question 1

Functions of
Respiratory System

Answer 1

Gas Exchange

Question 2

What are the parts of the respiratory system?

Answer 2

Upper respiratory tract

Lower respiratory tract

Question 3

What is included in the upper respiratory tract?

Answer 3

Nose

Mouth

Pharynx

Epiglottis

Larynx

Trachea

Question 4

What is the signifigance of the Carina and mainstem bronchus?

Answer 4

It is very sensitive. It will initiate an extreme cough when deep sunctioning

Question 5

What is included in the lower respiratory tract?

Answer 5

Bronchi

Bronchioles

Alveolar ducts

Alveoli

Lung lobes

Question 6

Parts of the airway conducting and respiratory

Answer 6

Question 7

Pulmonary Functional Unit

Answer 7

Question 8

Pulmonary blood supply includes…..

Answer 8

Pulmonary

Bronchial-

Bronchial circulation is where oxygen is givent ot the bronchi and other pulmonary tissue

Question 9

Whats included in the chest wall?

Answer 9

Ribs

Pleura

Diaphragm

Question 10

Where does gas exchange occur?

Answer 10

The Alveoli

Question 11

What is considered “dead space” and why

Answer 11

The trachea and Bronchi because ther is no gas exchange

Question 12

What is the purpose of an incentive spirometer?

Answer 12

Alveolar cells secrete surfactant when stretched. The purpose of IS is to stretch the aveoli and increase lung capacity decreasing chances of a collasped lung and infection

Question 13

What are the 3 parts of the physiology of respiration?

Answer 13

Ventilation

Compliance

Diffusion

Question 14

What occurs in ventilation?

Answer 14

Inspiration

Expiration

Question 15

What is compliance?

Answer 15

How much your langs can expand

Question 16

What occurs in diffusion?

Answer 16

CO2 and O2 go back and forth

until equilibrium is achieved

Question 17

What are ways to check Blood oxygen levels?

Answer 17

Arterial blood gases

Mixed venous blood gases

Oximetry

Question 18

PaO2 And SpO2 critical levels

Answer 18

Question 19

What does SpO2 and PaO2 Messure?

Answer 19

SpO2= Tissue perfusion

PaO2= partial pressure of oxygen in the blood

Question 20

What is included in the objective data in assessment of the upper respiratory tact?

Answer 20

Nose

Mouth and pharynx

Neck

Question 21

Steps to assess the thorax and lungs

Answer 21

Inspection

Palpation

Percussion

Ausculation

Question 22

Whats involved in Insepction?

Answer 22

1. any evidence of respiratory distress, such as tachypnea or use of accessory muscles.
2. the shape and symmetry of the chest. Chest movement should be equal on both sides
3. pectus carinatum [a prominent protrusion of the sternum
4. pectus excavatum [an indentation of the lower sternum above the xiphoid process]
5. respiratory rate, depth, and rhythm.

Question 23

Whats involved in palpation?

Answer 23

1. Palpation-Normal Expansion is 1 inch-2.54 cm-feel for tactile fremitus
2. used to determine tracheal position

Question 24

How should percussion and asculation of the chest be done?

Answer 24

Percussion and auscultation of the chest should be performed in a planned sequence from top to bottom. It is important to compare sounds side to side

Question 25

How do you percuss the lungs?

Answer 25

tap over lung tissue

Question 26

How to asculate breath sounds

Answer 26

instruct the patient to breathe slowly and a little deeper than normal through the mouth. Auscultation should proceed from the lung apices to the bases, comparing opposite areas of the chest, unless the patient is in respiratory distress or will tire easily; if so, start at the bases.

Question 27

What is another word for abnormal breath sounds?

Answer 27

Adventitious Sounds

Question 28

Examples of Adventitious breath sounds

Answer 28

Fine crackles-Sounds like rubbing your hair together Coarse crackles-bubbling Rhonchi-rumbling/snoring sound Wheezes-high pitch and squeaky Stridor-obstruction of larynx&trachea-Sounds like a crow ***Pleural friction rub-Grating/creaking sound. If you hear it while holding your breath its cardiac\*\*\*\*\*\*\*\*\****

Question 29

What are normal breath sounds?

Answer 29

vesicular bronchovesicular bronchial

Question 30

What is vesicular breath sounds?

Answer 30

sounds that are relatively soft, low-pitched, gentle, rustling sounds. They are heard over all lung areas except the major bronchi. Vesicular sounds have a 3:1 ratio, with inspiration 3 times longer than expiration

Question 31

What are Bronchovesicular sounds

Answer 31

They have a medium pitch and intensity and are heard anteriorly over the mainstem bronchi on either side of the sternum and posteriorly between the scapulae. Bronchovesicular sounds have a 1:1 ratio, with inspiration equal to expiration

Question 32

What are Bronchial Sounds?

Answer 32

Bronchial sounds are louder and higher pitched and resemble air blowing through a hollow pipe. Bronchial sounds have a 2:3 ratio with a gap between inspiration and expiration. This reflects the short pause between the respiratory cycles. To hear the likeness of bronchial breath sounds, place the stethoscope alongside the trachea in the neck.

Question 33

What are some Diagnostic Studies of Respiratory System?

Answer 33

Sputum Studies: Spontaneous Induced Sputum with hypertonic saline solution Skin Tests Allergies TB Bronchoscopy- Deeper sunctioning

Question 34

What is bronchoscopy?

Answer 34

* Bronchoscopy is a procedure in which the bronchi are visualized through a fiberoptic tube. * Bronchoscopy may be used for diagnostic purposes to obtain biopsy specimens and assess changes resulting from treatment. Small amounts (30 mL) of sterile saline may be injected through the scope and withdrawn and examined for cells, a technique termed bronchoalveolar lavage (BAL). * Bronchoscopy is also used for treatment. For example, mucous plugs or foreign bodies can be removed. Laser therapy, electrocautery, cryotherapy, and stents may be placed through a bronchoscope to achieve patency of an airway that has been completely or partially obstructed by tumors. Bronchoscopy can be performed in an outpatient procedure room, in a surgical suite, or at the bedside in the intensive care unit or on a medical-surgical unit, with the patient lying down or seated. After the nasal pharynx and oral pharynx are anesthetized with local anesthetic, the bronchoscope is coated with lidocaine (Xylocaine) and inserted, usually through the nose, and threaded down into the airways. Bronchoscopy can be done on mechanically ventilated patients through the endotracheal tube

Question 35

Other Diagnostic Studies of Respiratory System

Answer 35

Lung Biopsy Transbronchial Percutaneous/transthoracic needle aspiration (TTNA) Video-assisted thoracic surgery (VATS) Open biopsy

Question 36

Transbronchial Biopsy

Answer 36

Question 37

Thoracentesis

Answer 37

Question 38

What isThoracentesis?

Answer 38

Aspiration of pleural fluid or air from pleural space Stinging sensation and feeling of pressure Correct position Motionless patient Follow-up assessment for complications ***Hold anticoagulants***