Chapter 27: Assessment of the Respiratory System STUDY GUIDE

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A patient comes into the health care provider's office for an annual physical. The patient reports having a persistent, nagging cough. Which question does the nurse ask first about this symptom?
A."When did the cough start?"
B."Do you have a family history of lung cancer?"
C."Have you been running a fever?"
D."Do you have sneezing and congestion?"
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A patient comes into the health care provider's office for an annual physical. The patient reports having a persistent, nagging cough. Which question does the nurse ask first about this symptom?
A."When did the cough start?"
B."Do you have a family history of lung cancer?"
C."Have you been running a fever?"
D."Do you have sneezing and congestion?"
A."When did the cough start?"
When blood passes through the lungs, what happens to oxygen?
A.It diffuses from the alveoli into the red blood cells
B.It diffuses from the red blood cells to the alveoli
C.It decreases concentration in the blood
D.It decreases concentration in the alveoli
A.It diffuses from the alveoli into the red blood cells
In which situation would the oxygen dissociation curve shift to the left?
A.Decreased pH (Acidosis)
B.Increased pH (Alkalosis)
C.Increased body temperature
D.Increased body carbon dioxide concentration
B.Increased pH (Alkalosis)
Which respiratory changes occur as a result of aging? (Select all that apply)
A.Increased elastic recoil
B.Dilation of alveolar ducts
C.Decreased ability to cough
D.Alveolar surface tension increases
E.Diffusion capacity decreases
B.Dilation of alveolar ducts
C.Decreased ability to cough
E.Diffusion capacity decreases
The nurse is assessing a middle-aged patient who reports a decreased tolerance for exercise and that she must work harder to breathe. Which questions assist the nurse in determining what these changes are related to?
(Select all that apply)
A."Do you have anemia?"
B."When did you first notice these symptoms?"
C."Do you or have you ever smoked cigarettes?"
D."How often do you exercise?"
E."Are you coughing up any colored sputum?"
A."Do you have anemia?"
B."When did you first notice these symptoms"
C."Do you or have you ever smoked cigarettes?"
E."Are you coughing up any colored sputum?"
A patient who received a bronchoscopy was NPO for several hours before the test. Now a few hours after the test, the patient is hungry and would like a meal. What does the nurse do before allowing the patient to eat?
A.Order a meal because the patient is now alert and oriented
B.Check pulse oximetry to be sure oxygen saturation has returned to normal
C.Check for a gag reflex before allowing the patient to eat
D.Assess for nausea from the medications given for rest
C.Check for a gag reflex before allowing the patient to eat
After a bronchoscopy procedure, the patient coughs up sputum which contains blood. What is the best nursing action at this time?
A.Assess vital signs and respiratory status and notify the provider of the findings
B.Monitor the patient for 24 hours off to see if blood continues in the sputum
C.Send the sputum to the lab for cytology for possible lung cancer
D.Reassure the patient this is a normal response after a bronchoscopy
A.Assess vital signs and respiratory status and notify the provider of the findings
The nurse is caring for several patients who had diagnostic testing for respiratory disorders. Which diagnostic test has the highest risk for the postprocedure complication of pneumothorax?
A.Bronchoscopy
B.Laryngoscopy
C.Computed tomography of lungs
D. Percutaneous lung biopsy
D. Percutaneous lung biopsy
A patient's pulse oximetry reading is 89%. What is the nurse's first priority action?
A.Recheck the reading with a different oximeter
B. Apply supplemental oxygen and recheck the oximeter reading in 15 minutes
C.Assess the patient for respiratory distress and recheck the oximeter reading
D.Place the patient in the recovery position and monitor frequently
C.Assess the patient for respiratory distress and recheck the oximeter reading
A patient demonstrates labored, shallow respirations and a respiratory rate of 32/min with a pulse oximetry reading of 85%. What is the priority nursing intervention?
A.Notify respiratory therapy to give the patient a breathing treatment
B.Start oxygen via nasal cannula at 2 L/min
C.Obtain an order for a stat arterial blood gas (ABG)
D.Encourage coughing and deep breathing exercises
B.Start oxygen via nasal cannula at 2L/min
Which sounds in the smaller bronchioles and alveoli indicate normal lung sounds? A.Harsh, hollow, tubular blowing B.Nothing: normally no sounds are heard C.Soft, low rustling; like wind in the trees D.Flat, dull tones with a moderate pitchC.Soft, low rustling; like wind in the treesWhat in the characteristics of normal lung sounds that should be heard throughout the lung fields? A.Short inspiration, long expiration, loud, harsh B.Soft sound, long inspiration, short quiet expiration C.Mixed sounds of harsh and soft, long inspiration and expiration D.Loud, long inspiration and loud short expirationB.Soft sound, long inspiration, short quiet expirationUpon assessing the lungs, the nurse hears short, discrete popping sounds like "hair being rolled between fingers near the ear", in the bilateral lower lobes. How is this assessment documented? A.Rhonchi B.Wheezes C.Fine crackles D.Coarse cracklesC.Fine cracklesThe nurse is taking a history on a patient who reports sleeping in a recliner chair at night because lying on the bed causes shortness of breath. How is this documented? A.Orthopnea B.Paroxysmal nocturnal dyspnea C.Orthostatic nocturnal dyspnea D.TachypneaA.OrthopneaWhat observations does the nurse make when performing a general assessment of a patient's lung and thorax? (Select all that apply) A.Symmetry of chest movement B.Rate, rhythm, and depth of respirations C.Use of accessory muscles for breathing D.Comparison of the anteroposterior diameter with the lateral diameter E.Measurement of the length of the chest cavity F.Assessment of chest expansion and respiratory excursionA.Symmetry of chest movement B.Rate, rhythm, and depth of respirations C.Use of accessory muscles for breathing D.Comparison of the anteroposterior diameter with the lateral diameter F.Assessment of chest expansion and respiratory excursionWhich assessment finding is an objective sign of chronic oxygen deprivation? A.Continuous cough productive of clear sputum B.Audible inspiratory and expiratory wheeze C.Chest pain that increases with deep inspiration D.Clubbing of fingernails and a barrel shaped chestD.Clubbing of fingernails and a barrel shaped chestThe nurse reviews the CBC results for the patient who has COPD and lives in a high mountain area. What lab results does the nurse expect to see for this patient? A.Increased RBCs B.Decreased neutrophils C.Decreased eosinophils D.Increased lymphocytesA.Increased RBCsWhat is the best position for a patient to assume for a thoracocentesis? A.Side-lying, affected side exposed, head slightly raised B.Lying flat with arm on affected side across the chest C.Sitting up, leaning forward on the overbed table D.Prone position with arms above the head.C.Sitting up, leaning forward on the overbed tableA patient who had a thoracentesis is now experiencing the following manifestations: Rapid shallow respirations, rapid heart rate, and pain on the affected side that is worse at the end of inhalation. What complication does the nurse suspect this patient has developed? A.Hemoptysis B.Lung abscess C.Pneumothorax D.Lung cancerC.PneumothoraxThe nurse has just received a patient from the recovery room who is somewhat drowsy, but is capable of following instructions. Pulse oximetry has dropped from 95% to 90%. What is the nurse's priority nursing intervention? A.Administer oxygen at 2 L/min by nasal cannula, then reassess B.Have the patient perform coughing and deep breathing exercises, then reassess C.Administer naloxone to reverse narcotic sedation effect D. With-hold narcotic pain medication to reduce sedation effectA.Administer oxygen at 2 L/min by nasal cannula then reassesWhat is a pulse oximeter used to measure? A.Oxygen perfusion to extremities B.Pulse and perfusion in the extremities C.Generalized tissue perfusion D.Hemoglobin saturationD.Hemoglobin saturationThe nurse is performing a respiratory assessment including pulse oximetry on several patients. What conditions or situations may cause an artificially low reading? (Select all that apply) A.Fever B.Anemia C.Receiving narcotic pain medication D.Peripheral artery disease E.History of respiratory disease such as cystic fibrosis or tuberculosisB.Anemia D.Peripheral artery diseaseThe nurse hears fine crackles during a lung assessment of the patient who is in the initial postoperative period. Which nursing intervention helps relieve this respiratory problem? A.Monitor the patient with a pulse oximeter B.Encourage coughing and deep breathing C.Obtain an order for a chest xray D.Obtain an order for a high-flow oxygenB.Encourage coughing and deep breathingA patient having respiratory difficulty has a pH of 7.48. What is the nurse's best interpretation of this value? A.Acidosis B.Alkalosis C.Chronic respiratory illness D.Shortness of breathB.Alkolosis