Respiratory assessment parameters
can they talk without losing their breath, normal RR 12-20, O2 >92% on RA, regular rate and rhythm, non-labored, symmetrical chest rise and fall, cap refill <3 seconds, no use of accessory muscles
On auscultation of a patient's lungs, the nurse hears low-pitched, bubbling sounds during inhalation in the lower third of both lungs. How should the nurse document this finding?a. inspiratory crackles at the basesb. expiratory wheezes in both lungsc. abnormal lung sounds in the apices of both lungsd. pleural friction rub in the right and left lower lobes
crackles are ___, ___ sounds usually heard on ___
low-pitched; bubbling; inspiration
___ are high-pitched sounds that can be heard during expiratory or inspiratory phase of the respiratory cycle
The nurse palpates the posterior chest while the patient says "99" and notes absent fremitus.Which action should the nurse take next?a. Palpate the anterior chest and observe for barrel chest.b. Encourage the patient to turn, cough, and deep breathe.c. Review the chest x-ray report for evidence of pneumonia.d. Auscultate anterior and posterior breath sounds bilaterally.
a palpable vibration from the spoken voice felt over the chest wall
___ may be noted with pneumothorax or atelectasis
A patient with a chronic cough is scheduled to have a bronchoscopy with biopsy. Whichintervention will the nurse implement directly after the procedure?a. Encourage the patient to drink clear liquids.b. Place the patient on bed rest for at least 4 hours.c. Keep the patient NPO until the gag reflex returns.d. Maintain the head of the bed elevated 90 degrees.
The nurse completes a shift assessment on a patient admitted in the early phase of heartfailure. When auscultating the patient's lungs, which finding would the nurse most likelyhear?a. Continuous rumbling, snoring, or rattling sounds mainly on expirationb. Continuous high-pitched musical sounds on inspiration and expirationc. Discontinuous, high-pitched sounds of short duration during inspirationd. A series of long-duration, discontinuous, low-pitched sounds during inspiration
A patient admitted to the emergency department complaining of sudden onset shortness ofbreath is diagnosed with a possible pulmonary embolus. How should the nurse prepare thepatient for diagnostic testing to confirm the diagnosis?a. Ensure that the patient has been NPO.b. Start an IV so contrast media may be given.c. Inform radiology that radioactive glucose preparation is needed.d. Instruct the patient to expect to inspire deeply and exhale forcefully.
The nurse admits a patient who has a diagnosis of an acute asthma attack. Which statement indicates that the patient may need teaching regarding medication use?a. "I have not had any acute asthma attacks during the past year."b. "I became short of breath an hour before coming to the hospital."c. "I've been taking Tylenol 650 mg every 6 hours for chest wall pain."d. "I've been using my albuterol inhaler more frequently over the last 4 days.
The nurse analyzes the results of a patient's arterial blood gases (ABGs). Which findingwould require immediate action?a. The bicarbonate level (HCO3-) is 31 mEq/L.b. The arterial oxygen saturation (SaO2) is 92%.c. The partial pressure of CO2 in arterial blood (PaCO2) is 31 mm Hg.d. The partial pressure of oxygen in arterial blood (PaO2) is 59 mm Hg.
A patient in metabolic alkalosis is admitted to the emergency department and pulse oximetry(SpO2) indicates that the O2 saturation is 94%. Which action should the nurse expect to takenext?a. Complete a head-to-toe assessment.b. Administer an inhaled bronchodilator.c. Place the patient on high-flow oxygen.d. Obtain repeat arterial blood gases (ABGs).
The laboratory has just called with the arterial blood gas (ABG) results on four patients.Which result is most important for the nurse to report immediately to the health careprovider?a. pH 7.34, PaO2 82 mm Hg, PaCO2 40 mm Hg, and O2 sat 97%b. pH 7.35, PaO2 85 mm Hg, PaCO2 50 mm Hg, and O2 sat 95%c. pH 7.46, PaO2 90 mm Hg, PaCO2 32 mm Hg, and O2 sat 98%d. pH 7.31, PaO2 91 mm Hg, PaCO2 50 mm Hg, and O2 sat 96%
. The nurse teaches a patient with chronic bronchitis about a new prescription for AdvairDiskus (combined fluticasone and salmeterol). Which action by the patient would indicate tothe nurse that teaching about medication administration has been successful?a. The patient shakes the device before use.b. The patient rapidly inhales the medication.c. The patient attaches a spacer to the Diskus.d. The patient performs huff coughing after inhalation.
loud, lower pitched sound than normal resonance; heard over hyperinflated lungs, such as chronic obstructive lung disease and acute asthma
drum like loud empty quality sound heard over pneumothorax
Sound with medium-intensity pitch and duration heard over areas of "mixed" solid and lung tissue, such as over top area of liver, partially consolidated lung tissue (pneumonia) or fluid filled pleural space.
soft, high-pitched sound of short duration heard over very dense tissue where air is most present, such as posterior chest below level of diaphragm
series of short duration, discontinuous, high pitched sounds heard just before the end of inspiration; result of rapid equalization of gas pressure when collapsed alveoli or terminal bronchioles suddenly snap open; similar sound to that of hair being rolled between fingers just behind ear
causes of fine crackles
Atelectasis, fibrosis, pulmonary edema, early phase of heart failure
series of long duration discontinuous low pitched sounds caused by air passing through airway intermittently occluded by mucus, unstable bronchial wall. Evident on inspiration and, at times, expiration. Similar sound to blowing through a straw underwater. Increase in bubbling quality with more fluid.
causes of coarse crackles
excessive fluid within the lungs, HF, pulmonary edema, COPD, pneumonia w severe congestion
continuous, high-pitched squeak or musical sound made as air moves through narrowed or partially obstructed airway passages. First evident on expiration, but possibly evident on inspiration.
causes of wheezes
bronchospasm (caused by asthma), airway obstruction (caused by foreign body, tumor), COPD
continuous adventitious sound comprised of a very high-pitched wheeze that can be heard with inspiration and expiration and also indicates upper airway obstruction. stridor that is heard without a stethoscope can indicate an emergency
causes of stridor
croup, epiglottitis, vocal cord edema after extubation, foreign body
absent breath sounds
no sound evident over entire lung or area of lung.
causes of absent breath sounds
pneumothorax, pleural effusion, mainstem bronchus obstruction, large atelectasis, pneumonectomy, lobectomy
pleural friction rub
creaking or grating sound from roughened, inflamed surfaces of the pleura rubbing together, evident during inspiration, expiration, or both and no change with coughing; usually uncomfortable, especially on deep inspiration.
pleural friction rub causes
pleurisy, pneumonia, pulmonary infarct
The emergency department nurse is evaluating the effectiveness of therapy for a patient whohas received treatment during an asthma attack. Which assessment finding is the bestindicator that the therapy has been effective?a. No wheezes are audible.b. O2 saturation is >90%.c. Accessory muscle use has decreased.d. Respiratory rate is 16 breaths/minute.
A patient seen in the asthma clinic has recorded daily peak flow rates that are 75% of thebaseline. Which action will the nurse plan to take next?a. Increase the dose of the leukotriene inhibitor.b. Teach the patient about the use of oral corticosteroids.c. Administer a bronchodilator and recheck the peak flow.d. Instruct the patient to keep the scheduled follow-up appointment.
The home health nurse is visiting a patient with chronic obstructive pulmonary disease(COPD). Which nursing action is appropriate to implement for a nursing diagnosis ofimpaired breathing pattern related to anxiety?a. Titrate O2 to keep saturation at least 90%.b. Teach the patient how to use pursed-lip breathing.c. Discuss a high-protein, high-calorie diet with the patient.d. Suggest the use of over-the-counter sedative medications.
. The nurse is caring for a patient with cor pulmonale. The nurse should monitor the patient forwhich expected finding?a. Chest painb. Finger clubbingc. Peripheral edemad. Elevated temperature
The nurse is admitting a patient diagnosed with an acute exacerbation of chronic obstructivepulmonary disease (COPD). How should the nurse determine the appropriate O2 flow rate?a. Minimize O2 use to avoid O2 dependency.b. Maintain the pulse oximetry level at 90% or greater.c. Administer O2 according to the patient's level of dyspnea.d. Avoid administration of O2 at a rate of more than 2 L/min.
A patient is receiving 35% O2 via a Venturi mask. To ensure the correct amount of O2delivery, which action by the nurse is important?a. Teach the patient to keep the mask on during meals.b. Keep the air entrainment ports clean and unobstructed.c. Give a high enough flow rate to keep the bag from collapsing.d. Drain moisture condensation from the corrugated tubing every hour.
A face mask and reservoir bag device that delivers specific concentrations of oxygen by mixing oxygen with inhaled air.
Postural drainage with percussion and vibration is ordered twice daily for a patient withchronic bronchitis. Which intervention should the nurse include in the plan of care?a. Schedule the procedure 1 hour after the patient eats.b. Maintain the patient in the lateral position for 20 minutes.c. Give the prescribed albuterol (Ventolin HFA) before the therapy.d. Perform percussion before assisting the patient to the drainage position.
The nurse notes new onset confusion in an older patient who is normally alert and oriented. Inwhich order should the nurse take the following actions? (Put a comma and a space betweeneach answer choice [A, B, C, D].)a. Obtain the O2 saturation.b. Check the patient's pulse rate.c. Document the change in status.d. Notify the health care provider.
a, b, d, c
After assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis ofineffective airway clearance. Which assessment data best supports this diagnosis?a. Weak cough effortb. Profuse green sputumc. Respiratory rate of 28 breaths/minuted. Resting pulse oximetry (SpO2) of 85%
The nurse assesses the chest of a patient with pneumococcal pneumonia. Which finding wouldthe nurse expect?a. Increased tactile fremitus b. Dry, nonproductive coughc. Hyperresonance to percussiond. A grating sound on auscultation
A patient with bacterial pneumonia has coarse crackles and thick sputum. Which actionshould the nurse plan to promote airway clearance?a. Restrict oral fluids during the day.b. Teach pursed-lip breathing technique.c. Assist the patient to splint the chest when coughing.d. Encourage the patient to wear the nasal O2 cannula.
Which action should the nurse plan to prevent aspiration in a high-risk patient?a. Turn and reposition an immobile patient at least every 2 hours.b. Place a patient with altered consciousness in a side-lying position.c. Insert a nasogastric tube for feeding a patient with high calorie needs.d. Monitor respiratory symptoms in a patient who is immunosuppressed.
A patient with right lower-lobe pneumonia has been treated with IV antibiotics for 3 days.Which assessment data obtained by the nurse indicates that the treatment is effective?a. Bronchial breath sounds are heard at the right base.b. The patient coughs up small amounts of green mucus.c. The patient's white blood cell (WBC) count is 9000/μL.d. Increased tactile fremitus is palpable over the right chest.
The health care provider writes an order for bacteriologic testing for a patient who has apositive tuberculosis skin test. Which action should the nurse take?a. Teach about the reason for the blood tests.b. Schedule an appointment for a chest x-ray.c. Teach the patient about providing specimens for 3 consecutive days.d. Instruct the patient to collect several separate sputum specimens today.
A patient is admitted with active tuberculosis (TB). The nurse should question a health careprovider's order to discontinue airborne precautions unless which assessment finding isdocumented?a. Chest x-ray shows no upper lobe infiltrates.b. TB medications have been taken for 6 months.c. Mantoux testing shows an induration of 10 mm.d. Sputum smears for acid-fast bacilli are negative.
The nurse teaches a patient about the transmission of pulmonary tuberculosis (TB). Whichstatement, if made by the patient, indicates that teaching was effective?a. "I will take the bus instead of driving."b. "I will stay indoors whenever possible."c. "My spouse will sleep in another room."d. "I will keep the windows closed at home.
An older patient is receiving standard multidrug therapy for tuberculosis (TB). The nurseshould notify the health care provider if the patient exhibits which finding?a. Yellow-tinged sclerab. Orange-colored sputumc. Thickening of the fingernailsd. Difficulty hearing high-pitched voices
Employee health test results reveal a tuberculosis (TB) skin test of 16-mm induration and anegative chest x-ray for a staff nurse working on the pulmonary unit. The nurse has nosymptoms of TB. Which information should the occupational health nurse plan to teach thestaff nurse?a. Use and side effects of isoniazidb. Standard four-drug therapy for TBc. Need for annual repeat TB skin testingd. Bacille Calmette-Guérin (BCG) vaccine
The nurse monitors a patient in the emergency department after chest tube placement for ahemopneumothorax. The nurse is most concerned if which assessment finding is observed?a. A large air leak in the water-seal chamberb. 400 mL of blood in the collection chamberc. Complaint of pain with each deep inspirationd. Subcutaneous emphysema at the insertion site
___ is right ventricular HF caused by pulmonary hypertension
The nurse administers prescribed therapies for a patient with cor pulmonale and right-sidedheart failure. Which assessment could be used to evaluate the effectiveness of the therapies?a. Observe for distended neck veins.b. Auscultate for crackles in the lungs.c. Palpate for heaves or thrills over the heart.d. Monitor for elevated white blood cell count.
A patient with idiopathic pulmonary arterial hypertension (IPAH) is receiving nifedipine(Procardia). Which assessment would best indicate to the nurse that the patient's condition isimproving?a. Patient's chest x-ray indicates clear lung fields.b. Heart rate is between 60 and 100 beats/minute.c. Patient reports a decrease in exertional dyspnea.d. Blood pressure (BP) is less than 140/90 mm Hg.
A patient is diagnosed with both human immunodeficiency virus (HIV) and activetuberculosis (TB) disease. Which information obtained by the nurse is most important tocommunicate to the health care provider?a. The Mantoux test had an induration of 7 mm.b. The chest-x-ray showed infiltrates in the lower lobes.c. The patient has a cough that is productive of blood-tinged mucus.d. The patient is being treated with antiretrovirals for HIV infection
A patient with a possible pulmonary embolism complains of chest pain and difficultybreathing. The nurse finds a heart rate of 142 beats/min, blood pressure of 100/60 mm Hg, andrespirations of 42 breaths/min. Which action should the nurse take first?a. Administer anticoagulant drug therapy.b. Notify the patient's health care provider.c. Prepare patient for a spiral computed tomography (CT).d. Elevate the head of the bed to a semi-Fowler's position.
A patient is admitted to the emergency department with an open stab wound to the left chest.What action should the nurse take?a. Keep the head of the patient's bed positioned flat.b. Cover the wound tightly with an occlusive dressing.c. Position the patient so that the left chest is dependent.d. Tape a nonporous dressing on three sides over the wound.
. The nurse notes that a patient has incisional pain, a poor cough effort, and scattered coarsecrackles after a thoracotomy. Which action should the nurse take first?a. Assist the patient to sit upright in a chair.b. Splint the patient's chest during coughing.c. Medicate the patient with prescribed morphine.d. Observe the patient use the incentive spirometer.
The nurse is caring for a patient with idiopathic pulmonary arterial hypertension (IPAH).Which assessment information requires the most immediate action by the nurse?a. The O2 saturation is 90%.b. The blood pressure is 98/56 mm Hg.c. The epoprostenol (Flolan) infusion is disconnected.d. The international normalized ratio (INR) is prolonged.
After change-of-shift report, which patient should the nurse assess first?a. A 72-yr-old with cor pulmonale who has 4+ bilateral edema in his legs and feetb. A 28-yr-old with a history of a lung transplant and a temperature of 101° F (38.3°C)c. A 40-yr-old with a pleural effusion who is complaining of severe stabbing chest paind. A 64-yr-old with lung cancer and tracheal deviation after subclavian catheterinsertion
Which factors will the nurse consider when calculating the CURB-65 score for a patient withpneumonia (select all that apply)?a. Age b. Blood pressure c. Respiratory rated. O2 saturatione. Presence of confusionf. Blood urea nitrogen (BUN) level
a, b, c, e, f
Which diagnostic test will provide the nurse with the most specific information to evaluatethe effectiveness of interventions for a patient with ventilatory failure?a. Chest x-rayb. O2 saturationc. Arterial blood gas analysisd. Central venous pressure monitoring
While caring for a patient who has been admitted with a pulmonary embolism, the nurse notesa change in the patient's oxygen saturation (SpO2) from 94% to 88%. Which action should thenurse take?a. Suction the patient's oropharynx.b. Increase the prescribed O2 flow rate.c. Instruct the patient to cough and deep breathe.d. Help the patient to sit in a more upright position.
A patient with respiratory failure has a respiratory rate of 6 breaths/min and an oxygensaturation (SpO2) of 88%. The patient is increasingly lethargic. Which intervention will thenurse anticipate?a. Administration of 100% O2 by non-rebreather maskb. Endotracheal intubation and positive pressure ventilationc. Insertion of a mini-tracheostomy with frequent suctioningd. Initiation of continuous positive pressure ventilation (CPAP)
A nurse is caring for an obese patient with right lower lobe pneumonia. Which position willbe best to improve gas exchange?a. On the left sideb. on the right sidec. in the tripod positiond. in the high fowler's position
aThe patient should be positioned with the "good" lung in the dependent position to improvethe match between ventilation and perfusion. The obese patient's abdomen will limitrespiratory excursion when sitting in the high-Fowler's or tripod positions
A patient develops increasing dyspnea and hypoxemia 2 days after heart surgery. Todetermine whether the patient has acute respiratory distress syndrome (ARDS) or pulmonaryedema caused by heart failure, the nurse will plan to assist witha. obtaining a ventilation-perfusion scan.b. drawing blood for arterial blood gases.c. positioning the patient for a chest x-ray.d. insertion of a pulmonary artery catheter.
dpulmonary artery wedge pressures are normal in the patient with ARDS bc the fluid in the alveoli is caused by increased permeability of the alveolar-capillary membrane rather than by the backup of fluid from the lungs (as occurs with cardiogenic pulmonary edema)
A nurse is caring for a patient with ARDS who is being treated with mechanical ventilationand high levels of positive end-expiratory pressure (PEEP). Which assessment finding by thenurse indicates that the PEEP may need to be reduced?a. The patient's PaO2 is 50 mm Hg and the SaO2 is 88%.b. The patient has subcutaneous emphysema on the upper thorax.c. The patient has bronchial breath sounds in both the lung fields.d. The patient has a first-degree atrioventricular heart block with a rate of 58 beats/min.
bthe subQ emphysema indicates barotrauma caused by positive pressure ventilation and PEEP. Bradycardia, hypoxemia, and bronchial breath sounds are all concerns and will need to be addressed, but they are not specific indications that PEEP should be reduced
Which statement by the nurse when explaining the purpose of positive end-expiratorypressure (PEEP) to the patient's caregiver is accurate?a. "PEEP will push more air into the lungs during inhalation."b. "PEEP prevents the lung air sacs from collapsing during exhalation."c. "PEEP will prevent lung damage while the patient is on the ventilator."d. "PEEP allows the breathing machine to deliver 100% O2 to the lungs.
bby preventing alveolar collapse during expiration, PEEP improves gas exchange and oxygenation. PEEP will not prevent lung damage, push more air into the lungs, or change the fraction of inspired oxygen delivered to the pt
A nurse is caring for a patient who is orally intubated and receiving mechanical ventilation.To decrease the risk for ventilator-associated pneumonia, which action will the nurse includein the plan of care?a. Elevate head of bed to 30 to 45 degrees.b. Give enteral feedings at no more than 10 mL/hr.c. Suction the endotracheal tube every 2 to 4 hours.d. Limit the use of positive end-expiratory pressure.
aelevation of the head decreases the risk for aspiration.
A patient with acute respiratory distress syndrome (ARDS) who is intubated and receivingmechanical ventilation develops a right pneumothorax. Which collaborative action will thenurse anticipate next?a. Increase the tidal volume and respiratory rate.b. Decrease the fraction of inspired oxygen (FIO2).c. Perform endotracheal suctioning more frequently.d. Lower the positive end-expiratory pressure (PEEP).
dbecause barotrauma is associated with high airway pressure, the level of PEEP should be decreased The other actions will not decrease the risk for another pneumothorax
After receiving change-of-shift report on a medical unit, which patient should the nurse assessfirst?a. A patient with cystic fibrosis who has thick, green-colored sputumb. A patient with pneumonia who has crackles bilaterally in the lung basesc. A patient with emphysema who has an oxygen saturation of 90% to 92%d. A patient with septicemia who has intercostal and suprasternal retractions
D this patient's history of septicemia and labored breathing suggest the onset of ARDS, which will require rapid intervention such as administration of O2 and use of positive pressure ventilation.
The nurse is caring for an older patient who was hospitalized 2 days earlier withcommunity-acquired pneumonia. Which assessment information is most important tocommunicate to the health care provider?a. Persistent cough of blood-tinged sputum.b. Scattered crackles in the posterior lung bases.c. Oxygen saturation 90% on 100% O2 by nonrebreather mask.d. Temperature 101.5° F (38.6° C) after 2 days of IV antibiotics.
cthe pt's low SpO2 despite receiving a high fraction of inspired oxygen indicates the possibility of acute respiratory distress syndrome
nurse is caring for a patient with acute respiratory distress syndrome (ARDS) who isreceiving mechanical ventilation using synchronized intermittent mandatory ventilation(SIMV). The settings include fraction of inspired oxygen (FIO2) of 80%, tidal volume of 450,rate of 16/minute, and positive end-expiratory pressure (PEEP) of 5 cm. Which assessmentfinding is most important for the nurse to report to the health care provider?a. O2 saturation of 99%b. HR 106 beats/minutec. crackles audible at lung basesd. respiratory rate 22 breaths/minute
athe FIO2 of 80% increases the risk for O2 toxicity. Because O2 sat is 99%, a decrease in FIO2 is indicated to avoid toxicity
The nurse is caring for a patient who is intubated and receiving positive pressure ventilation totreat acute respiratory distress syndrome (ARDS). Which finding is most important to reportto the health care provider?a. Red-brown drainage from nasogastric tubeb. Blood urea nitrogen (BUN) level 32 mg/dLc. Scattered coarse crackles heard throughout lungsd. Arterial blood gases: pH of 7.31, PaCO2 of 50, and PaO2 of 68
athe nasogastric drainage indicates possible GI bleeding or stress ulcer and should be reported.
Which actions should the nurse start to reduce the risk for ventilator-associated pneumonia(VAP) (select all that apply)?a. Obtain arterial blood gases daily.b. Provide a "sedation holiday" daily.c. Give prescribed pantoprazole (Protonix).d. Elevate the head of the bed to at least 30°.e. Provide oral care with chlorhexidine (0.12%) solution daily
b, c, d, e