Respiratory Assessment Flashcards
Meet the Client: Mr. Winston Winchell
Mr. Winston Winchell is a 70-year-old African-American. He has a history of emphysema and has been admitted to an inpatient medical unit with an acute respiratory infection. The nurse prepares to complete the client’s admission assessment after his transfer from the emergency department.
Info
Priority Data Collection 1. To ensure that the client's respiratory status is stable upon arrival on the medical unit, which assessment should the nurse complete first? Breath sounds. Oxygen saturation. Level of fatigue. Chest excursion.
Oxygen saturation.
Measurement of the client’s oxygen saturation provides information about the effectiveness of gas exchange. A low oxygen saturation level requires immediate nursing intervention.
The initial assessment of Mr. Winchell upon arrival on the unit continues. The nurse measures the client’s vital signs. His respiratory rate is 32 breaths per minute.
2.
What follow-up assessment data should the nurse obtain first?
Cigarette smoking history.
Use of accessory muscles.
Cultural health beliefs.
Color of sputum.
Use of accessory muscles.
Use of accessory muscles indicates an increased respiratory effort by the client and provides data that the client may be experiencing respiratory distress.
Client Interview
The nurse applies oxygen at 2 liters per minute via a nasal cannula and ensures that the client is comfortable. His oxygen saturation is stable at 95%, and his respiratory rate decreases to 24 breaths per minute. Mr. Winchell reports that he feels able to continue with the admission interview and assessment.
3.
After answering a few questions, the client begins to cough. What assessment should the nurse perform?
Assess for the presence of nail bed clubbing.
Review oral fluid intake for the last 24 hours.
Observe for dryness of the oral mucosa.
Note the amount and appearance of any sputum.
Note the amount and appearance of any sputum.
The amount and appearance of any sputum when the client coughs provides useful data related to the cause of the client’s cough and any underlying problems.
Mr. Winchell’s cough is non-productive.
4.
After Mr. Winchell stops coughing, the nurse continues the interview. To assess the client’s history related to dyspnea on exertion (DOE), what question should the nurse ask Mr. Winchell?
“Do you become short of breath while lying flat?”
“What activities cause you to feel short of breath?”
“How frequently do you experience difficulty breathing?”
“Are you having trouble catching your breath right now?”
“What activities cause you to feel short of breath?”
The type of activity and the amount of physical effort should elicit information about the client’s DOE.
The nurse asks Mr. Winchell about his history of cigarette smoking. Mr. Winchell tells the nurse that he smoked 2 packs of cigarettes per day for over 40 years, but then he quit smoking 10 years ago. He then looks away and remarks that he is very fatigued from answering all the interview questions.
5.
How should the nurse respond?
Continue the interview and assessment, avoiding further questions related to cigarette smoking.
Restrict visitors so that the client can rest, and return later to complete the interview and assessment.
Advise the client to rest in the bed while the nurse performs a physical assessment of the client.
Document that the physical assessment could not be performed because of the client’s level of fatigue.
Advise the client to rest in the bed while the nurse performs a physical assessment of the client.
Since it is important to obtain as much assessment data as possible to ensure the client’s physiologic stability, the nurse should continue with the client’s physical assessment but allow the client to rest by curtailing the interview.
Physical Assessment: Observation While Mr. Winchell rests, the nurse continues the physical assessment. The nurse observes the appearance of Mr. Winchell's thorax and notes that the ratio of his anteroposterior and transverse chest diameters is 1:1. 6. How should this finding be documented? Within normal limits. Funnel chest. Barrel chest. Thoracic scoliosis.
Barrel chest. Correct
A barrel chest is the description for an increased anteroposterior (AP) to transverse ratio. The normal ratio is 1:2, so a 1:1 ratio represents an increased ratio.
The nurse observes Mr. Winchell for outward signs of hypoxemia. The nurse notes that Mr. Winchell's thoracic skin color is dark brown, consistent with his African-American ethnicity, and his nail beds are pink. 7. What additional assessment will provide supporting data related to hypoxemia? (Select all that apply.) Color of palms and soles. Evidence of lower leg swelling. Presence and location of chest hair. Multiple thoracic hemangiomas. Shape of the fingers and fingertips.
Color of palms and soles.
Cyanosis, a bluish tinge typically signifying tissue hypoxia, is most evident in the nail beds, lips, and buccal mucosa. In dark-skinned persons, cyanosis may also be evident in the palms of the hands and soles of the feet.
Shape of the fingers and fingertips.
Nail clubbing is associated with chronic hypoxemia. It develops in stages including fluctuation and softening of the nail, loss of the normal angle, increased convexity of the nail fold, thickening of the distal end of the finger and a shiny aspect and striation of the nail.
Physical Assessment: Palpation The nurse reviews landmarks on the anterior chest and locates the Angle of Louis. 8. Locating the Angle of Louis is important to guide the nurse in next locating what area? Xiphoid process. Erb's point. Clavicle. Second rib.
Second rib.
The second ribs attach to the sternum at the Angle of Louis, or sternal angle. This landmark is located at the bottom of the manubrium of the sternum, and is felt as a bony ridge, and is the point where the treachea bifurcates into the right and left stem bronchi.
Mr. Winchell asks to sit on the side of the bed. After assisting him to this position, the nurse continues the assessment facing Mr. Winchell’s back and placing both hands on his posterolateral chest at the level of T9.
9.
To assess chest excursion, what should the nurse do next?
Ask the client to inhale deeply.
Encourage the client to cough.
Tap lightly over the middle finger.
Instruct the client to hold his breath.
Ask the client to inhale deeply.
To assess chest excursion, the nurse observes the movement of the hands placed on the lower posterior thorax as the client inhales.
10.
The nurse observes symmetric chest excursion. What action should the nurse take?
Ask the client to cough before repeating the assessment.
Document the normal finding on the assessment record.
Question the client about a recent history of rib fractures.
Stop the assessment and measure the client’s vital signs.
Document the normal finding on the assessment record.
Because chest excursion should be symmetric, i.e., equal on both sides, the nurse should document this normal finding on the assessment record. No additional intervention is warranted. If the chest excursion is asymmetric, the nurse should take further action to determine the cause of the asymmetry.
The nurse next plans to palpate for vocal fremitus.
11.
Recalling the client’s admission diagnosis of emphysema and an acute pulmonary infection, what finding should the nurse anticipate?
Diminished fremitus over areas of infection.
Increased fremitus over areas of consolidation.
Absent fremitus over areas of hyperinflated alveoli.
Inability to assess for fremitus due to fatigue.
Increased fremitus over areas of consolidation.
Increased fremitus, or vibration when the client speaks, is often felt over areas of consolidated lung tissue, such as in clients with pneumonia.
12.
To begin the assessment for vocal fremitus, what should the nurse do?
Place one hand over each scapula.
Locate the posterior axillary line.
Assist the client to lie back in the bed.
Ask the client to repeat a phrase aloud.
Ask the client to repeat a phrase aloud.
Vocal fremitus is assessed by palpating for vibrations on the thoracic wall beginning at the apex and ending at the base of the lungs while the client repeats a word or phrase aloud.
Physical Assessment: Percussion
Since Mr. Winston is still comfortable sitting on the side of the bed leaning over a bedside table, the nurse next prepares to percuss the client’s thorax.
13.
In order to percuss the client’s thorax posteriorly beginning at the apex of the right lung, how should the nurse begin?
Palpate the space directly below the clavicle.
Place one finger pad over the first rib.
Locate the client’s first intercostal space.
Find the space directly above the diaphragm.
Locate the client’s first intercostal space.
Percussion should be performed systematically, percussing in the intercostal spaces to avoid the ribs and scapulae.
The nurse percusses the client’s lungs bilaterally and notes dullness in the lung bases.
14.
What follow-up action should the nurse implement?
Compare this finding with the location of the client’s pneumonia seen on x-ray.
Review the client’s medical history to determine how long he has had emphysema.
Document this normal assessment finding in the client’s admission assessment.
Notify the healthcare provider that the client may have developed a pneumothorax.
Compare this finding with the location of the client’s pneumonia seen on x-ray.
Dullness upon percussion should be anticipated over areas of abnormal density, including pneumonia. The nurse can confirm this assessment finding by reviewing the location of the client’s pneumonia found on x-ray.
