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Respiratory assessme
Nursing
| Question | Answer |
|---|---|
| A nurse is assessing a male client with chronic airflow limitations and notes that the client has a "barrel chest." The nurse interprets that this client has which of the following forms of chronic airflow limitations? | Emphysema |
| What is atelectasis? | collapse of the alveoli in the lung prevents normal exchange of O2 and co2 hypoventilation occurs |
| A seven-month-pregnant female is sitting quietly in the waiting room, and her respiratory rate is 20 and shallow. What does this finding suggest to the nurse? | c. Nothing. This is normal. |
| The nurse is planning to assess the apex of a client's lungs. Which area of the body will the nurse be assessing? | Above the clavicles |
| Prior to listening to a client's lung sounds, the nurse palpates the sternum and feels a horizontal bump on the bone. What does this finding suggest to the nurse? | This is the angle of Louis. |
| The nurse is assessing the client's lung bases posteriorly. At which area can the nurse assess this portion of the lung? | Scapular Line |
| the mother of a four-year-old child tells the nurse, "I think there's something wrong with him; his chest is round like a ball." Which of the following would be an appropriate response for the nurse to make to the mother? | The chest of a child appears round and is normal. |
| A 57-year-old client tells the nurse, "I need two to three pillows to sleep." How should this information be documented? | Two to Three pillow orthopnea |
| Gas exchange takes place in the | Alveoli |
| The sternal angle is also known as | angle of louis |
| Soft and low-pitched breath sounds normally heard over most of both lungs are | Vesicular |
| High-pitched breath sounds are best heard by using | diaphragm of the stethescope |
| Which continuous breath sounds are relatively high pitched with a hissing or shrill quality? | Wheezes |
| Normal breath sounds heard over most of both lungs are described as being a. loud | Soft |
| Which is correct about vesicular breath sounds? | Inspiratory sounds last longer than expiratory |
| Which percussion note would you hear over the airless area in atelectasis | dull |
| Wheezes most commonly suggest a. secretions in large airways | Narrowed airways |
| Findings in a patient with pneumothorax include | decreased to absent breath sounds |
| cyanosis | purplish color of skin due to lack of oxygen in tissues |
| hypoxia | lack of oxygen in the tissues |
| tachypnea | fast breathing, above 24 (or 20), fear anxiety and exercise causes it |
| normal repiratory rate: | 12-20 |
| bradypnea: | less than 10, normal in athletes, caused by certain medicines |
| hyperventilation: | increased rate in depth (anxiety/extreme exercise) |
| hypoventilation: | decreased rate and depth , caused by overdose in narcotics |
| Kussmaul: | rapid, deep labored breathing-only time is diabetic-fruity breath |
| cheyne-stokes- | rapid deep periods of breathing followed by long periods of not breathing |
| when would you see cheyne stokes: | congestive heart failure (CHF), drug OD, renal failure, increased intracranial pressure |
| Biot's: | irregular breathing/varying rate in depth....clinical indication=meningitis |
| air trapping: | patient cant breath out/exhale properly (COPD) |
| diagnostic test where the fluid is drained from the lungs by a needle: | THORACENTESIS |
| Lung biopsy and bronchioscopy: | in a lung biopsy, piece of tissue is extracted and a bronchiocopy may be done at the same time to look down the airway with a tube inserted/light in order to view air way strucutres and also be better able to grap a tissue sample |
| hemoptysis: | blood in the sputum |
| CBC: | infection or anemia screening (RBC) |
| sputum sample: | detects infection or Tuberculosis (hack up/put in cup) |
| fatty protein that reduces surface tension in the alveoli: | surfactant |
| continuous smooth membrane composed of two surfaces that totally encloses the lungs: | pleura |
| Pack-Years: | way to document the smoking history-number of packs smokes PER DAY, X multiplied by the number of years patient smoked |
| intermittent dypnea during speak, sudden onset of breathing difficulty severe enough to wake the patient: | PND paroxysmal nocturnal disease |
| orthopnea: | shortness of breath that occurs when lying down, but is relieved by sitting up |
| normally the ribs slope: | downward |
| vibration of the chest wall produced when the patient speaks: | tactile (vocal) fremitus |
| Mediastinal shift: | shift of central thoracic structures toward one side (chest X ray is performed to rule this out) |
| Pneumothorax: | partial or complete collapse of the lung |
| atelectasis: | alveolar collapse (gas exchange is reduced b/c alveolar surface area is reduced) |
| low/soft normal breath sounds: | vesicular |
| high/loud normal breath sounds: | Bronchial |
| Medium/moderate | bronchovesicular |
| Which adventitious sound would your hear in Tuberculosis, pneumonia, and lung cancer: | pleural friction rub |
| which sound might you hear if a patient has a tumor: | rhonchus OR low pitched crackles (character for both is low pitched) |
| which sound would you hear if a patient has bronchitis: | crackles |
| pneumonia sounds (2): | PLEURAL FRICTION RUB AND FINE CRACKLES |
| normal breath sound heard over the trachea/larynx: | bronchial (high/loud) |
| The left lung is _ and _ ; and divided into_: | narrower and smaller....divided into 2 lobes |
| right lung has: | 3 lobes |
| 60-65% of lung functioning occurs in the: | RIGHT LUNG |
| microscopic examination where pleural fluid may be drained to relieve blood vessel or lung compresstion / respiratory distress: | Thoracentesis |
| asses tactile fremitis where? | over the anterior chest wall |
| use the ___ of the stethoscope to assess children? | bell |
| breath sounds are normally much __ in children: | louder |
| in older adults, chest movement normally ___ | declines |
| if abnormalties are detected during tactile fremitis or auscultation, perform the... | vocal resonance tests "ninety-nine" (normal- sound is muffled) |
| infants have an almost ___ shaped chest: | round |
| how to PALPATE for tactile fremitis: | with fingers, begin at lung apex (top), and have patient say "ninety-nine"each time hand is placed *not done by 'auscultating' |
| where do you begin palpating for tactile fremitis at (on anterior and posterior thorax): | begin at lung APEX for both (apex = top) |
| API or point of maximal impulse : | apex actually touches chest wall at the fourth to fifth intercostal space just medial to the left midclavicular line |
Created by:
lje0002