Chapter 30Assessment of Respiratory Function My Nursing Test Banks

Chapter 30Assessment of Respiratory Function

MULTIPLE CHOICE

1.A client is experiencing the ventilation-perfusion mismatch termed shunting. The nurse realizes that the client most likely is not experiencing which of the following disorders?

1.

Hemothorax

2.

Intrapulmonary fistulas

3.

Pneumothorax

4.

Pulmonary embolus

ANS: 4

Shunting is the portion of the cardiac output that does not exchange with alveolar air. Examples of shunting include hemothorax, pneumothorax, and intrapulmonary fistulas. Pulmonary embolus is the other type of ventilation-perfusion mismatch called dead space.

PTS: 1 DIF: Analyze REF: Ventilation-Perfusion Dysfunction

2.A client has a slight shift to the left on the oxygen-hemoglobin dissociation curve. Which of the following assessment findings will support this curve configuration?

1.

Arterial pH less than 7.35

2.

Increased levels of 2,3-diphosphoglycerate

3.

Hyperthermia

4.

Hypothermia

ANS: 4

Factors that cause increased affinity of oxygen for hemoglobin will shift the oxyhemoglobin dissociation curve to the left. These factors include alkalemia and hypothermia. Arterial pH less than 7.35, increased leaves of 2,3-diphosphoglycerate, and hyperthermia indicate a shift to the right, not the left.

PTS: 1 DIF: Analyze REF: Oxygen-Hemoglobin Dissociation Curve

3.A client, experiencing an acid-base imbalance, demonstrates signs of full compensation within 3 days. The nurse realizes that the full compensation was accomplished by which of the following systems?

1.

Extracellular buffer

2.

Intracellular buffer

3.

Pulmonary

4.

Renal

ANS: 4

The extracellular and intracellular buffer systems act immediately, the pulmonary system acts within 2 to 3 hours, and the renal system responds within 2 to 3 days.

PTS: 1 DIF: Analyze REF: Compensatory Mechanisms

4.A client with a nasogastric tube connected to low continuous suction has the following arterial blood gas (ABG) results: pH 7.49, PaO2 91, PaCO2 42, and HCO3 31. Interpreting these result, the nurse concludes that the client is in:

1.

metabolic acidosis.

2.

metabolic alkalosis.

3.

respiratory acidosis.

4.

respiratory alkalosis.

ANS: 2

Because the pH is greater than 7.45, this is not an acidosis. The PaCO2 is within normal limits. The HCO3 is elevated. An elevated pH and HCO3 indicates metabolic alkalosis.

PTS: 1 DIF: Analyze REF: Arterial Blood Gas Analysis

5.A client is demonstrating signs of respiratory alkalosis. The nurse realizes that this alteration is least likely caused by which of the following?

1.

Diarrhea

2.

Fever

3.

Pain

4.

Severe anemia

ANS: 1

Diarrhea is a cause of metabolic acidosis. Causes of the respiratory alkalosis are hypoxia, increased minute ventilation, hyperventilation, pregnancy, fever, pain, and severe anemia.

PTS: 1 DIF: Analyze REF: Table 30-1 Causes of Acid-Base Imbalances

6.A client has a productive cough that produces green sputum with a musty odor. The nurse realizes that the client may be experiencing:

1.

emphysema.

2.

pneumococcal pneumonia.

3.

Pseudomonas infection.

4.

pulmonary edema.

ANS: 3

A client with a Pseudomonas infection can have a cough that produces green sputum with a musty odor. The sputum from emphysema is gray-white and mucoid. The sputum from pneumococcal pneumonia and pulmonary edema are rust colored and pink, frothy, respectively.

PTS: 1 DIF: Analyze REF: Table 30-2 Sputum in Pulmonary Conditions

7.A client is experiencing a gradual increase of pleuritic pain. In which of the following pulmonary conditions would the nurse expect to see this type of pain?

1.

Pneumococcal pneumonia

2.

Pneumothorax

3.

Pulmonary embolism

4.

Tuberculosis

ANS: 4

A more gradual onset of pleuritic pain is seen in tuberculosis and malignancy. Acute pleuritic pain is associated with pneumococcal pneumonia, pneumothorax, and pulmonary embolism.

PTS: 1 DIF: Analyze REF: Assessment: History Taking

8.The nurse is assessing a client diagnosed with emphysema. Which of the following will most likely be assessed during the clients physical examination?

1.

Barrel chest

2.

Pectus carinatum

3.

Pectus excavatum

4.

Scoliosis

ANS: 1

Barrel chest is often seen in chronic emphysema as a result of long-term air trapping. Pectus carinatum is an abnormal protuberance of the sternum, and pectus excavatum is an abnormal depression of the sternum.

PTS:1DIF:ApplyREF:Skeletal Deformities

9.The nurse is assessing an adult patient experiencing hypoxia. Which of the following findings would be considered a late sign of hypoxia?

1.

Confusion

2.

Cyanosis

3.

Drowsiness

4.

Headache

ANS: 2

Cyanosis is a late sign of hypoxia. Confusion, drowsiness, and headache are early signs.

PTS: 1 DIF: Analyze REF: Signs of Respiratory Distress

10.A client is diagnosed with a large pneumothorax. The percussion note the nurse would expect to find is:

1.

dullness.

2.

flatness.

3.

resonant.

4.

tympany.

ANS: 4

Air-filled areas have a percussion note of tympany. A resonant note can be elicited by percussing a patient with normal lungs. Flatness is heard over bone and dullness is heard over the organs.

PTS:1DIF:Apply

REF: Table 30-3 Percussion Notes and Associated Conditions

11.A client is demonstrating a crescendo-decrescendo pattern of breathing with periods of apnea. The nurse would document this breathing pattern as being:

1.

Cheyne-Stokes.

2.

apnea.

3.

bradypnea.

4.

Kussmaul.

ANS: 1

Cheyne-Stokes breathing is a pattern of crescendo-decrescendo breathing. Apnea is the absence of breathing. Bradypnea is a breathing rate of less than 12 respirations per minute. Kussmaul breathing is rapid and deep and often associated with diabetic ketoacidosis.

PTS: 1 DIF: Apply REF: Figure 30-14 Rhythms of Breathing

12.The nurse, assessing a clients breath sounds, has the stethoscope placed over the second intercostal space next to the sternum. The sound the nurse is most likely going to hear would be:

1.

vesicular.

2.

bronchovesicular.

3.

bronchial.

4.

absent.

ANS: 2

Bronchovesicular breath sounds are loud and harsh and are most likely heard over the trachea. Vesicular breath sounds can be heard anywhere over the lung fields. Bronchial sounds are only normally heard over the trachea. They are loud and harsh in quality, high-pitched, and sound hollow. Absent breath sounds can also be heard throughout the lung fields.

PTS: 1 DIF: Analyze REF: Table 30-4 Normal Breath Sounds

13.A client is determined to be a candidate for a low-flow oxygen delivery system. Which of the following will the nurse most likely assess in this client?

1.

Active bleeding

2.

Change in level of consciousness

3.

Cardiac arrhythmias

4.

Respiratory rate of 16, unlabored breathing

ANS: 4

Low-flow oxygen systems are used for clients who are clinically stable and have a normal ventilatory pattern such as the client with a respiratory rate of 16 and unlabored breathing. A high-flow oxygen system would be indicated for a client who is not clinically stable such as bleeding, change in level of consciousness, or who is experiencing cardiac arrhythmias.

PTS: 1 DIF: Apply REF: Oxygen Delivery Systems

MULTIPLE RESPONSE

1.The nurse is assessing a client for decreased fremitus. Which of the following conditions are associated with decreased fremitus? (Select all that apply.)

1.

Atelectasis

2.

Emphysema

3.

Pneumonia

4.

Pneumothorax

5.

Pulmonary fibrosis

6.

Pulmonary infarction

ANS: 1, 3, 5, 6

Atelectasis, pneumonia, pulmonary fibrosis, and pulmonary infarction cause decreased fremitus. Pneumothorax and emphysema would cause increased fremitus.

PTS: 1 DIF: Analyze REF: Fremitus

2.The nurse is documenting that a client has adventitious breath sounds. Which of the following would be considered this type of sound? (Select all that apply.)

1.

Rales

2.

Vesicular

3.

Rhonchi

4.

Wheeze

5.

Bronchovesicular

6.

Pleural friction rub

ANS: 1, 3, 4, 6

Adventitious breath sounds include rales, rhonchi, wheezes, and pleural friction rubs. Vesicular and bronchovesicular are considered normal breath sounds.

PTS: 1 DIF: Analyze REF: Table 30-5 Adventitious Breath Sounds

3.The nurse is assessing the thorax of an elderly client. Which of the following would be considered normal age-related changes in this clients respiratory system? (Select all that apply.)

1.

Hyperresonance

2.

Pain with inspiration

3.

Vital capacity reduced

4.

Hemoptysis

5.

Productive cough

6.

Wheezes

ANS: 1, 3

Normal age-related changes seen in the elderly include hyperresonance with palpation and a reduction in the vital capacity. Pain with inspiration, hemoptysis, productive cough, and wheezes are not normal age-related changes of the respiratory system.

PTS: 1 DIF: Analyze REF: Age-Related Changes in the Respiratory System

4.A client is scheduled for a ventilation-perfusion scan. The nurse realizes that this diagnostic test is used to diagnose which of the following? (Select all that apply.)

1.

Pulmonary emboli

2.

Congestive heart failure

3.

Bronchitis

4.

Asthma

5.

Pneumonia

6.

COPD

ANS: 1, 3, 4, 5, 6

The purpose of the ventilation-perfusion scan is to diagnose and locate pulmonary emboli. It is also helpful in  diagnosing bronchitis, asthma, pneumonia, COPD, and cancer. This scan is not used to diagnose congestive heart failure.

PTS: 1 DIF: Analyze REF: Ventilation-Perfusion Scan

5.A client is prescribed a bedside diagnostic test to assess pulmonary status. The nurse will prepare to administer which of the following to the client? (Select all that apply.)

1.

Capnography

2.

Thoracentesis

3.

Oximetry

4.

Bronchoscopy

5.

Polysomnography

6.

Lung biopsy

ANS: 1, 3, 5

The three diagnostic tests that can be administered at the bedside include capnography, which measures exhaled carbon dioxide; oximetry, which measures oxygenation; and polysomnography, which measures breathing while asleep. Thoracentesis, bronchoscopy, and lung biopsy are all invasive procedures and cannot be administered at the bedside.

PTS: 1 DIF: Apply REF: Bedside Monitoring Diagnostic Tests

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