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Chapter 14: Pulmonary Clinical Assessment and Diagnostic Procedures
Terms in this set (38)
Why would the nurse perform an inspection of the oral cavity during a complete pulmonary assessment?
a. To provide evidence of hypoxia
b. To provide evidence of dyspnea
c. To provide evidence of dehydration
d. To provide evidence of nutritional status
Severe hypoxia will be manifested by central cyanosis, which is evident in the oral and circumoral areas. Although dehydration and nutritional status can both be partially assessed by oral cavity inspection; this information is not as vital as determining hypoxia. Dyspnea means difficulty breathing.
Which of the following lung sounds would be most likely heard in a client experiencing an asthma attack?
a. Coarse rales
b. Pleural friction rub
c. Fine crackles
d. Expiratory wheezes
Wheezes are high-pitched, squeaking, whistling sounds produced by airflow through narrowed small airways. They are heard mainly on expiration but may also be heard throughout the ventilatory cycle. Depending on their severity, wheezes can be further classified as mild, moderate, or severe. Rales are crackling sounds produced by fluid in the small airways or alveoli or by the snapping open of collapsed airways during inspiration. A pleural friction rub is a dry, coarse sound produced by irritated pleural surfaces rubbing together and is caused by inflammation of the pleura.
Which of the following describes the major difference between tachypnea and hyperventilation?
a. Tachypnea has increased rate; hyperventilation has decreased rate.
b. Tachypnea has decreased rate; hyperventilation has increased rate.
c. Tachypnea has increased depth; hyperventilation has decreased depth. d. Tachypnea has decreased depth; hyperventilation has increased depth.
Tachypnea is manifested by an increase in the rate and decrease in the depth of ventilation. Hyperventilation is manifested by an increase in both the rate and depth of ventilation.
A patient presents with chest trauma from an MVA. Upon assessment, the nurse documents that the patient is complaining of dyspnea, shortness of breath, tachypnea, and tracheal deviation to the right. In addition, the client's tongue is blue-gray. Based on the following data, what the nurse would expect to find?
a. PaO2 of 88 and PCO2 of 55
b. Absent breath sounds in all right lung fields
c. Absent breath sounds in all left lung fields
d. Diminished breath sounds in all fields
The clinical picture described is most consistent with left pneumothorax. This would cause the trachea to deviate to the right, away from the increasing pressure of the left. A pneumothorax this severe would completely collapse the right lung, thus causing absent breath sounds in that lung.
On assessment of a client, you note fremitus over the trachea but not in the lung periphery. You know that this most likely represents
a. bilateral pleural effusion.
b. bronchial obstruction.
c. a normal finding.
d. apical pneumothorax.
Fremitus is described as normal, decreased, or increased. With normal fremitus, vibrations can be felt over the trachea but are barely palpable over the periphery. With decreased fremitus, there is interference with the transmission of vibrations. Examples of disorders that decrease fremitus include pleural effusion, pneumothorax, bronchial obstruction, pleural thickening, and emphysema.
Normal anteroposterior (AP) diameter ranges from 1:2 to 5:7. An increase in AP diameter of the chest that is characterized by displacement of the sternum forward and the ribs outward is indicative of
a. a funnel chest.
b. a pigeon breast.
c. a barrel chest.
d. Harrison's groove.
Normal ratio of anteroposterior diameter to lateral diameter ranges from 1:2 to 5:7. A barrel chest is characterized by displacement of the sternum forward and the ribs outward and is suggestive of chronic obstructive pulmonary disease. Funnel chest, pectus excavatum, creates a pit-shaped depression. Pigeon chest, pectus carinatum, causes an increase in anteroposterior diameter. Both are related to restrictive pulmonary disease. Harrison's groove, a rib deformity, is a result of rickets.
A patient is admitted to the unit in respiratory distress secondary to pneumonia. The nurse knows that obtaining a history is very important. What is the appropriate intervention at this time for obtaining this data?
a. Collect an overview of past medical history, present history, and current health
b. Do not obtain any history at this time.
c. Curtail the history to just a few questions about the client's chief complaint and
d. Complete the history and then provide measures to assist the client to breathe
The initial presentation of the client determines the rapidity and direction for the interview. For a client in acute distress, the history should be curtailed to just a few questions about the client's chief complaint and the precipitating events.
While conducting a physical assessment, you note that the patient's breathing is rapid and shallow. This type of breathing pattern is known as
c. obstructive breathing. d. bradypnea.
Tachypnea is manifested by an increase in the rate and decrease in the depth of ventilation. Hyperventilation is manifested by an increase in both the rate and depth of ventilation. Obstructive breathing is characterized by progressively more shallow breathing until the client actively and forcefully exhales. Bradypnea is a slow respiratory rate characterized as less than 12 breaths/min in an adult.
Which of the following is an example of a disorder with increased tactile fremitus? a. Emphysema
b. Pleural effusion
Examples of disorders that increase tactile fremitus include pneumonia, lung cancer, and pulmonary fibrosis. Emphysema, pleural effusion, and pneumothorax are disorders that decrease fremitus
Auscultation of the anterior chest should be performed using which of the following sequences?
a. Right side, top to bottom, then left side, top to bottom b. Left side, top to bottom, then right side, top to bottom c. Side to side, bottom to top
d. Side to side, top to bottom
Auscultation should be done in a systematic sequence: side to side, top to bottom, posteriorly, laterally, and anteriorly.
Diminished to absent breath sounds on the right side, tracheal deviation to the left side, and asymmetrical chest movement are indicative of which of the following disorders?
a. Tension pneumothorax
c. Pulmonary fibrosis d. Atelectasis
Diminished to absent breath sounds on the right side, tracheal deviation to the left side, and asymmetrical chest movement are indicative of tension pneumothorax.
The adventitious breath sounds that sound like popping in the small airways or alveoli are a. sonorous wheezes.
c. sibilant wheezes.
d. pleural friction rubs.
Crackles or rales are short, discrete, popping or crackling sounds produced by fluid in the small airways or alveoli.
Voice sounds such as bronchophony, egophony, and whispering pectoriloquy are increased in a. pneumonia with consolidation.
Voice sounds are increased in pneumonia with consolidation because there is increased vibration through material. Bronchophony and whispering pectoriloquy are heard as clear transmission of sounds on auscultation; egophony is heard as an "a" sound when the client is saying "e."
A patient is admitted to the critical care unit with acute respiratory failure secondary to chronic obstructive pulmonary disease. The patient has a 15-year history of emphysema and bronchitis. On inspection, the nurse observes that the patient is experiencing air trapping. While auscultating the chest, the nurse notes the presence of coarse, rumbling, low-pitched sounds in the right middle and lower lobes. On further inspection of the patient, the nurse observes that his fingers appear discolored. This is a result of
b. central cyanosis.
c. peripheral cyanosis. d. chronic tuberculosis.
Discoloration of the fingers is an indication of peripheral cyanosis. Central cyanosis occurs when the unsaturated hemoglobin of arterial blood exceeds 5 g/dL and is considered a life-threatening situation. Clubbing refers to an abnormality of the fingers caused by chronically low blood levels of oxygen often related to a heart or lung disease.
A patient is admitted to the critical care unit with acute respiratory failure secondary to COPD. The patient has a 15-year history of emphysema and bronchitis. On inspection, the nurse observes that the patient is experiencing air trapping. While auscultating the chest, the nurse notes the presence of coarse, rumbling, low-pitched sounds in the right middle and lower lobes. On percussion of the lung fields, a patient with emphysema will predictably exhibit which tone?
b. Hyperresonance c. Tympany
The percussion tone of hyperresonance is heard with emphysema related to overinflation of the lung. Resonance can be found in normal lungs or with the diagnosis of bronchitis. Tympany occurs with the diagnosis of large pneumothorax and emphysematous blebs. Dullness occurs with the diagnosis of atelectasis, pleural effusion, pulmonary edema, pneumonia, and a lung mass.
A patient is admitted to the critical care unit with acute respiratory failure. Upon auscultation, the health care provider hears creaking, leathery, coarse breath sounds in the lower anterolateral chest area during inspiration and expiration. The nurse suspects that the patient has a(n)
c. pulmonary fibrosis.
d. pleural friction rub.
A pleural friction rub is the result of irritated pleural surfaces rubbing together and is characterized by a leathery, dry, loud, coarse sound. A pleural friction rub is seen with pleural effusions or pleurisy and is not indicative of emphysema.
A patient is admitted to the critical care unit with acute respiratory failure secondary to COPD. The patient has a 15-year history of emphysema and bronchitis. On inspection, the nurse notes that the patient is experiencing air trapping. While auscultating his chest, you note the presence of coarse, rumbling, low-pitched sounds in the right middle and lower lobes. Which of the following best describes the patient's breathing pattern?
a. Deep sighing breaths without pauses
b. Rapid, shallow breaths
c. Normal breathing pattern interspersed with forced expirations d. Irregular breathing pattern with both deep and shallow breaths
Air trapping is described as a normal breathing pattern interspersed with forced expirations. As the patient breathes, air becomes trapped in the lungs, and ventilations become progressively shallower until the patient actively and forcefully exhales.
A client just involved in a motor vehicle accident has sustained blunt chest trauma as part of his injuries. The nurse assessment reveals absent breath sounds in the left lung field. A left-sided pneumothorax is suspected and is further validated when assessment of the trachea reveals
a. a shift to the right.
b. a shift to the left.
c. no deviation.
d. subcutaneous emphysema.
With a pneumothorax, the trachea shifts to the opposite side of the problem; with atelectasis, the trachea shifts to the same side as the problem. Subcutaneous emphysema is more commonly related to a pneumomediastinum and is not specifically related to the trachea but to air trapped in the mediastinum and general neck area.
Diaphragmatic excursion is a measurement of the difference in the level of the diaphragm on inspiration and expiration determined by percussion. It is increased in
a. atelectasis and emphysema.
b. hepatomegaly and ascites.
c. atelectasis and paralysis.
d. pneumonia and pneumothorax.
Normal diaphragmatic excursion is 3 to 5 cm and is part of the percussion component of the physical examination. An assessment finding other than normal would indicate the need for further evaluation such as chest radiographic examination.
On admission, a patient presents as follows: pH, 7.38; respiratory rate, 24 breaths/min, regular, pursed-lip breathing; PaO2, 66 mm Hg; heart rate, 112 beats/min, sinus tachycardia; PaCO2, 52 mm Hg; blood pressure, 110/68 mm Hg; HCO3, 34 mEq/L; and SpO2, 90% on O2 2 L/min nasal cannula. These gases show
a. uncompensated metabolic alkalosis. b. uncompensated respiratory acidosis. c. compensated respiratory acidosis.
d. compensated respiratory alkalosis.
The pH is closer to the acidic level, so the primary disorder is acidosis. Compensated respiratory acidosis values include a pH of 7.35 to 7.39, PACO2 greater than 45 mm Hg, and HCO3 greater than 26 mEq/L. Uncompensated respiratory acidosis values include a pH below 7.35, PACO2 above 45 mm Hg, and HCO3− of 22 to 26 mEq/L. Compensated respiratory alkalosis values include a pH of 7.41 to 7.45, PACO2 below 35 mm Hg, and HCO3 below 22 mEq/L. Uncompensated metabolic alkalosis values include a pH above 7.45, PACO2 of 35 to 45 mm Hg, and HCO3− above 26 mEq/L
On admission, a patient presents as follows: pH, 7.38; respiratory rate, 24 breaths/min, regular, pursed-lip breathing; PaO2, 66 mm Hg; heart rate, 112 beats/min, sinus tachycardia; PaCO2, 52 mm Hg; blood pressure, 110/68 mm Hg; HCO3−, 24 mEq/L; and SpO2, 90% on O2 2 L/min nasal cannula. Which of the following diagnoses would be most consistent with the above arterial blood gas values?
a. Acute pulmonary embolism
b. Acute myocardial infarction
c. Congestive heart failure
d. Chronic obstructive pulmonary disease
The fact that the HCO3− level has increased enough to compensate for the increased pCO2 level indicates that this is not an acute condition because the kidneys can take several days to adjust. The other choices would present with a lower HCO3− level. The values indicate respiratory acidosis, and one of the potential causes is chronic obstructive pulmonary disease. Potential causes for respiratory alkalosis are pulmonary embolism, acute myocardial infarction, and congestive heart failure.
On admission, a patient presents as follows: pH, 7.38; respiratory rate, 24 breaths/min, regular, pursed-lip breathing; PaO2, 66 mm Hg; heart rate, 112 beats/min, sinus tachycardia; PaCO2, 52 mm Hg; blood pressure, 110/68 mm Hg; HCO3, 24 mEq/L; and SpO2, 90% on O2 2 L/min nasal cannula. What treatment would the physician or nurse practitioner likely order for this patient?
a. Increase O2 to 6 L/min.
b. Prepare for emergency intubation.
c. Administer 1 ampule of sodium bicarbonate. d. Repeat ABG testing in 4 hours.
Increasing the FiO2 on this patient could decrease the respiratory rate and increase the severity of the patient's CO2 retention. The patient's arterial blood gas (ABG) values do not warrant intubation at this time. Additional sodium bicarbonate is not indicated because this patient has a fully compensated pH. A repeat ABG may be ordered to assess the patient's ongoing respiratory status. Other factors must be considered when reviewing a patient's ABGs, including oxygen saturation, oxygen content, base excess and deficit, and anion gap analysis.
A patient's assessment data present as follows: pH, 7.10; PaCO2, 60 mm Hg; PaO2, 40 mm Hg; HCO3, 24 mEq/L; RR, 34 breaths/min; HR, 128 beats/min; and BP, 180/92 mm Hg. This condition is best described as
a. uncompensated respiratory acidosis.
b. uncompensated metabolic acidosis. c. compensated metabolic acidosis.
d. compensated respiratory acidosis.
The pH is below normal range (7.35-7.45), so this is uncompensated acidosis. The PaCO2 is markedly elevated, and the HCO3 is normal. This indicates uncompensated respiratory acidosis. Uncompensated respiratory acidosis values include a pH below 7.35, PACO2 above 45 mm Hg, and HCO3 of 22 to 26 mEq/L. Uncompensated metabolic acidosis values include a pH below 7.35, PACO2 of 35 to 45 mm Hg, and HCO3 above 22 mEq/L. Compensated metabolic acidosis values include a pH of 7.35 to 7.39, PACO2 below 35 mm Hg, and HCO3− below 22 mEq/L. Compensated respiratory acidosis values include a pH of 7.35 to 7.35, PACO2 above 45 mm Hg, and HCO3 above 26 mEq/L.
In a patient who is hemodynamically stable, which procedure can be used to estimate the PaCO2 levels?
a. PaO2/FIO2 ratio
b. A-a gradient
c. Residual volume (RV) d. End-tidal CO2
Capnography is the measurement of exhaled carbon dioxide (CO2) gas; it is also known as end-tidal CO2 monitoring. Normally, alveolar and arterial CO2 concentrations are equal in the presence of normal V/Q relationships. In a patient who is hemodynamically stable, the end-tidal CO2 (Petco2) can be used to estimate the PaCO2. Normally, the PaO2/FiO2 ratio is greater than 286; the lower the value, the worse the lung function. The a?2-a gradient (P[a ?2- a]O2) is normally less than 20 mm Hg on room air for patients younger than 61 years. This estimate of intrapulmonary shunting is the least reliable clinically, but it is used often in clinical decision making. Residual volume is the amount of air left in the lung after maximal exhalation. A normal value is 1200 to 1300 mL.
A patient presents with the following values: pH, 7.20; paO2, 106 mm Hg; paCO2, 35 mm Hg; and HCO3−, 11 mEq/L. These values are most consistent with
a. uncompensated respiratory acidosis.
b. uncompensated metabolic acidosis.
c. uncompensated metabolic alkalosis. d. uncompensated respiratory alkalosis.
The pH indicates acidosis, and the HCO3− is markedly decreased, indicating a metabolic disorder. Uncompensated metabolic acidosis values include a pH below 7.35, PACO2 of 35 to 45 mm Hg, and HCO3− above 22 mEq/L. Uncompensated respiratory acidosis values include a pH below 7.35, PACO2 above 45 mm Hg, and HCO3− of 22 to 26 mEq/L. Uncompensated respiratory alkalosis values include a pH above 7.45, PACO2 below 35 mm Hg, and HCO3− of 22 to 26 mEq/L. Uncompensated metabolic alkalosis values include a pH above 7.45, PACO2 of 35 to 45 mm Hg, and HCO3− above 26 mEq/L.
For which of the following conditions is a bronchoscopy indicated?
a. Pulmonary edema
b. Ineffective clearance of secretions
c. Upper gastrointestinal bleed
d. Instillation of surfactant
Bronchoscopy visualizes the bronchial tree. If secretions are present, they can be removed by suctioning and sent for culture to help adjust antibiotic therapy.
A patient presents moderately short of breath and dyspneic. A chest radiographic examination reveals a large right pleural effusion with significant atelectasis. The physician or nurse practitioner would be most likely to order which of the following procedures?
c. Ventilation/perfusion (V/Q) scan d. Repeat chest radiograph
Thoracentesis is a procedure that can be performed at the bedside for the removal of fluid or air from the pleural space. It is used most often as a diagnostic measure; it may also be performed therapeutically for the drainage of a pleural effusion or empyema. No evidence is present that would necessitate a V/Q scan. A bronchoscopy cannot assist in fluid removal. A problem with this chest radiograph is not indicated.
V/Q scans are ordered to evaluate the possibility of which of the following? a. Pulmonary emboli
b. Acute myocardial infarction
d. Acute respiratory distress syndrome
This test is ordered for the evaluation of pulmonary emboli. Electrocardiography or cardiac enzymes are ordered to evaluate for myocardial infarction; arterial blood gas analysis, chest radiography, and pulmonary function tests are ordered to evaluate for emphysema. Chest radiography and hemodynamic monitoring are ordered for evaluation of acute respiratory distress syndrome.
A patient with chronic obstructive pulmonary disease requires intubation. After the physician intubates the patient, the nurse auscultates for breath sounds. Breath sounds are questionable in this patient. Which action would best assist in determining endotracheal tube placement in this patient?
a. Stat chest radiographic examination b. End-tidal CO2 monitor
c. V/Q scan
d. Pulmonary artery catheter insertion
Although a stat chest radiography examination would be helpful, it has a long turnaround time, and the patient's respiratory status can deteriorate quickly. An end-tidal CO2 monitor gives an immediate response, and the tube can then be reinserted without delay if incorrectly placed. The other tests are not for endotracheal tube placement.
A patient's pulse oximeter alarm goes off. The monitor reads 82%. What is the first action the nurse should perform?
a. Prepare to intubate.
b. Assess the patient's condition.
c. Turn off the alarm and reapply the oximeter sensor. d. Increase O2 level to 4L/NC.
The first nursing action would be to assess the patient to see if there is a change in his or her condition. If the patient is stable, then the nurse would turn off the alarm and reapply the oximeter sensor. The pulse oximeter cannot differentiate between normal and abnormal hemoglobin. Elevated levels of abnormal hemoglobin falsely elevate the Spo2. The ability of a pulse oximeter to detect hypoventilation is accurate only when the patient is breathing room air. Because most critically ill patients require some form of oxygen therapy, pulse oximetry is not a reliable method of detecting hypercapnia and should not be used for this purpose.
Which of the following patients would be considered hypoxemic? a. A 70-year-old man with a PaO2 of 72
b. A 50-year-old woman with a PaO2 of 65
c. An 84-year-old man with a PaO2 of 96
d. A 68-year-old woman with a PaO2 of 80
Normal PaO2 is 80 to 100 mm Hg in persons younger than 60 years. The formula for determining PaO2 for a person older than 60 years of age is 80 mm Hg minus 1 mm Hg for every year of age above 60 years of age, for example, 70 years old = 80 mm Hg - 10 mm Hg = 70 mm Hg; 84 years old = 80 mm Hg - 20 mm Hg = 60 mm Hg; and 68 years old = 80 mm Hg - 8 mm Hg = 72 mm Hg.
Determination of oxygenation status by oxygen saturation alone is inadequate. What other value must be known?
d. Hemoglobin (Hgb)
Proper evaluation of the oxygen saturation level is vital. For example, an Sao2 of 97% means that 97% of the available hemoglobin is bound with oxygen. The word available is essential to evaluating the Sao2 level because the hemoglobin level is not always within normal limits and oxygen can bind only with what is available.
A patient is intubated, and sputum for culture and sensitivity is ordered. Which of the following is important for obtaining the best specimen?
a. After the specimen is in the container, dilute thick secretions with sterile water.
b. Apply suction when the catheter is advanced to obtain secretions from within the
c. Do not apply suction while the catheter is being withdrawn because this can
contaminate the sample with sputum left in the endotracheal tube.
d. Do not clear the endotracheal tube of all local secretions before obtaining the
To prevent contamination of secretions in the upper portion of the endotracheal tube, do not apply suction while the catheter is being withdrawn. Clear the endotracheal or tracheostomy tube for all local secretions, avoiding deep airway penetration. This will prevent contamination with upper airway flora. Do not dilute thick secretions with sterile water. This will compromise the specimen.
Severe coughing and shortness of breath during a thoracentesis are indicative of which of the following complications?
a. Re-expansion pulmonary edema
b. Pleural infection
Re-expansion pulmonary edema can occur when a large amount of effusion fluid (~1000-1500 mL) is removed from the pleural space. Removal of the fluid increases the negative intrapleural pressure, which can lead to edema when the lung does not re-expand to fill the space. The patient experiences severe coughing and shortness of breath. The onset of these symptoms is an indication to discontinue the thoracentesis.
Which of the following chest radiography findings is consistent with a left pneumothorax?
a. Flattening of the diaphragm
b. Shifting of the mediastinum to the right
c. Presence of a gastric air bubble
d. Increased radiolucency of the left lung field
Shifting of the mediastinal structures away from the area of involvement is a sign of a pneumothorax.
A patient is admitted with acute respiratory failure attributable to pneumonia. Smoking history reveals that the patient smoked two packs of cigarettes a day for 25 years, stopping 10 years ago. ABG values on the current ventilator settings are pH, 7.37; PaCO2, 50 mm Hg; and HCO3−, 27 mEq/L. Chest radiograph reveals a large right pleural effusion. Intrapulmonary shunting value of 35% indicates
a. normal gas exchange of venous blood.
b. an abnormal finding indicative of a shunt-producing disorder.
c. a serious and potentially life-threatening condition.
d. metabolic alkalosis.
A shunt greater than 10% is considered abnormal and indicative of a shunt-producing disorder. A shunt greater than 30% is a serious and potentially life-threatening condition that requires pulmonary intervention
Which of the following regarding the client history will assist the nurse in developing the plan of management? (Select all that apply.)
a. Provides direction for the rest of the assessment
b. Exposes key clinical manifestations
c. Aids in developing the plan of care
d. The degree of the client's distress determines the extent of the interview e. Determines length of stay in the hospital setting
ANS: A, B, C, D
The initial presentation of the patient determines the rapidity and direction of the interview. For a patient in acute distress, the history should be curtailed to just a few questions about the patient's chief complaint and precipitating events.
Risk factors that need to be considered with a thoracentesis include (Select all that apply.) a. coagulation defects.
b. intra-aortic balloon pump.
c. pleural effusion.
d. uncooperative patient. e. empyema.
ANS: A, B, D
No absolute contraindications to thoracentesis exist, although some risks may contraindicate the procedure in all but emergency situations. These risk factors include unstable hemodynamics, coagulation defects, mechanical ventilation, the presence of an intra-aortic balloon pump, and patients who are uncooperative. It is used most often as a diagnostic measure; it may also be performed therapeutically for the drainage of a pleural effusion or empyema.
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