RESPIRATORY HESI

RESPIRATORY HESI To ensure that the client's respiratory status is stable upon his arrival on the medical unit, the nurse should complete which assessment first? Oxygen saturation -Provides info about the effectiveness of gas exchange Pt.'s RR is 32 BPM. What follow-up assessment data should the nurse obtain first? Use of accessory muscles -Indicatesincreased respiratory effort -Pt. may be in respiratory distress After answering a few questions, the client begins to cough. What assessment should the nurse perform? Note the amount and appearance of any sputum After pt. stops coughing, the nurse continues the interview. To assess the client's history related to dyspnea on exertion (DOE), what question should the nurse ask Mr. Jackson? "What activities cause you to feel short of breath?" Nurse asks pt. about his history of smoking. He then looks away and remarks that he is very fatigued from answering all the interview questions. How should the nurse respond? Advise the client to rest in the bed while the nurse performs a physical assessment of the client. Ratio Anteroposterior and Transverse chest diameter is 1:1. How should this finding be documented? Barrel Chest -Increased AP:T ratio What assessment will provide supporting data related to hypoxemia? -Color of palms and soles --Cyanosis -Shape of the fingers and fingertips --Clubbing Locating the Angle of Louis is important to guide the nurse in next locating what area? 2nd rib -Attach to the sternum at the Angle of Louis, or sternal angle -Point where Trachea bifurcates Facing pts. back and placing both hands on his posterolateral chest at the level of T9. To assess chest excursion, what should the nurse do next? Ask the pt. to inhale deeply The nurse observes symmetric chest excursion. What action should the nurse take? Document the normal finding on the assessment record. The nurse plans to palpate for vocal fremitus. The client's admission diagnosis of emphysema and an acute pulmonary infection, what finding should the nurse anticipate? Increased fremitus over areas of consolidation. To begin the assessment for vocal fremitus, what should the nurse do? Ask the client to repeat a phrase aloud -Palpating for vibrations on the thoracic wall Upgrade to remove ads Only $3.99/month In order to percuss the client's thorax posteriorly beginning at the apex of the right lung, how should the nurse begin? Locate the client's first intercostal space The nurse percusses the client's lungs bilaterally and notes dullness in the lung bases. What follow-up action should the nurse implement? Compare this finding with the location of the client's pneumonia seen on x-ray. -Dullness should be anticipated over areas of abnormal density, including pneumonia. The nurse begins auscultating pts. breath sounds posteriorly by placing the diaphragm of the stethoscope over his left lung apex. After listening in this area, how should the nurse proceed? Move the diaphragm across to the apex of the right lung posteriorly Always compare bilaterally!! The nurse hears vesicular breath sounds when auscultating over the upper and middle lung fields posteriorly. What action should the nurse take? Auscultate the lower lung fields to determine the presence of any adventitious sounds Nurse hears crackles bilaterally in posterior lung bases. Nurse auscultates breath sounds anteriorly, hears high-pitched musical squeaking sounds in the Upper lobes during expiration. What action should the nurse take? Document the presence of wheezes in the upper lobes and complete assessment. Crackles could be heard bilaterally during the posterior auscultation of the lung bases. Nurse doesn't hear any adventitious sounds in the lung bases during anterior auscultation. What action should the nurse take? Chart what washeard both anteriorly and posteriorly Which assessment provides the most useful data related to the client's current nutritional status? Calculate the client's body mass index -Marker of the client's optimal weight for his height To assess the client for signs of protein malnutrition, what action should the nurse take? Note the texture of the client's hair. -Dull, dry, sparse hair may be an indication of nutritional deficiencies, protein deficiency. Nurse observes sputum in a tissue left at the bedside. The sputum is thick and purulent. What assessment should the nurse perform? Auscultate breath sounds bilaterally Nurse observes pt. is confused. Upon admission, pt. was oriented to person, place, and time. Nurse auscultates pt.'s breath sounds and hears an increase in crackles posteriorly, now in both the lower and middle lung fields. Which data is most important for the nurse to obtain before contacting the HCP? Respiratory effort -Confusion may be an indicator of decreasing oxygenation When recording the change in the client's assessment findings, how should the nurse document the breath sounds? Crackles heard bilaterally in the middle and lower lung fields posteriorly How should the nurse report the assessment data? Compare the current assessment of the client to the data obtained during the admission assessment of the client. The manubriosternal angle (angle of louis) is continuous with which anatomical landmark? Second Rib Which breath sounds, heard in the posterior bases, suggest atelectasis? Diminished breath sounds -Alveoli are collapsed Which finding on the pt. history is suspicious for pulmonary tuberculosis? Night sweats What assessment finding of the respiratory system in a 2 month old infant is considered abnormal? Grunting Which assessment finding suggests a child has epiglottitis Difficulty swallowing Pt. with metabolic acidosis is likely to display which type of respiration? Rapid deep regular breathing -Kussmaul respirations In which condition is fluid present in the pleural space? Pleural effusion Areas of hyperresonance are percussed over the lung fields in which condition? Emphysema -Trapped air 2 packs of cigarettes per day for 10 years. 1 pack per day for 15 years. How many pack years? 35