Question 1

The client is 36 weeks pregnant. The nurse is assessing the client's respiratory system and finds that the respiratory rate is 24 breaths per minute. The client states that she sometimes experiences shortness of breath. Which response by the nurse is the most appropriate?

Accepted Answer

During the last trimester of pregnancy, it is common for clients to experience shortness of breath and an increased respiratory rate due to the growing uterus and hormonal changes. Option A is incorrect as it presents a diagnosis without further assessment or confirmation. Option C is incorrect as notifying the healthcare provider is not necessary for normal physiologic changes. Option D is incorrect as there is no indication that the client has been infected with tuberculosis.

Question 2

A preschool client's respiratory rate is 30 per minute. The mother states, "That seems like a really high number. My healthcare provider told me my respiratory rate is only 16 per minute." Which response by the nurse is the most appropriate?

Accepted Answer

The respiratory rate of 30 per minute is within the normal range for a preschool-aged child, which is typically higher than that of an adult.

Question 3

The nurse is assessing a 1-month-old infant's respiratory system and sees that the infant is primarily using abdominal muscles to breathe and has an irregular breathing pattern. Which conclusion by the nurse is appropriate based on this observation?

Accepted Answer

It is normal for infants to primarily use abdominal muscles to breathe and have an irregular breathing pattern during the first few months of life. This is due to immature respiratory control and is not necessarily indicative of respiratory distress or illness.

Question 4

A client is experience tachypnea with anxiety and is "hyperventilating." Based on this assessment, which finding does the nurse anticipate for this client?

Accepted Answer

Hyperventilation leads to excessive exhalation of carbon dioxide (CO2), resulting in decreased CO2 levels in the blood, not increased. This can cause symptoms such as lightheadedness, tingling in the limbs, and sometimes anxiety or panic.

Question 5

The nurse is preparing to assess an older adult client diagnosed with emphysema. Which anatomical change does the nurse anticipate when performing this client's assessment?

Accepted Answer

Emphysema is a type of chronic obstructive pulmonary disease (COPD) that causes damage to the air sacs in the lungs, leading to difficulty in exhalation. This results in an enlarged and overinflated chest, commonly known as a barrel chest. Funnel chest and pigeon chest are structural abnormalities of the chest wall, while scoliosis is a sideways curvature of the spine and does not directly relate to the anatomical changes associated with emphysema.

Question 6

The nurse is caring for an adolescent client who is hospitalized with asthma. Several peers are preparing to visit the client and have brought gifts. Which gift will the nurse prevent from being placed in the client's room?

Accepted Answer

Fresh flowers can harbor pollen and other allergens that could exacerbate asthma symptoms, making them an inappropriate gift for someone hospitalized with asthma.

Question 7

As the nurse assesses the pregnant client, the client states that she sometimes feels like she has difficulty breathing. The client has reached the 36th week of her pregnancy. Which is the reason that the client is experiencing this phenomenon?

Accepted Answer

As the fetus grows and gets bigger in the uterus, it can push the diaphragm upwards and cause difficulty breathing, particularly in the later weeks of pregnancy. This is a common occurrence and is not usually a cause for concern unless it is severe or accompanied by other symptoms. Fatigue, anxiety, and contractions can also be causes of difficulty breathing, but are less likely in this scenario.

Question 8

The nurse is percussing the anterior chest of an older adult client. Which finding does the nurse anticipate for this client based on the age?

Accepted Answer

In older adults, hyperresonance may be heard due to age-related changes such as decreased lung elasticity and possible air trapping.

Question 9

The nurse is examining an African American client. When compared to Caucasian client, which conditions is this client at a higher risk for developing?

Accepted Answer

The answer of The nurse is examining an African American...

Question 10

A client with chronic bronchitis is admitted to the hospital. The nurse inspects the client while assessing the client's respiratory system. Which assessment finding is expected?

Accepted Answer

Use of accessory muscles is expected in a client with chronic bronchitis as the body is trying to compensate for the impaired air flow by using additional muscles to aid in breathing. Fever, decreased respiratory rate, and dry cough are not specific to chronic bronchitis and may or may not be present.

Question 11

The nurse is preparing an educational program regarding Healthy People 2020. Which pieces of information are important to include for caregivers of infants and young children?

Accepted Answer

B) "Children should be taught to wash their hands." Hand washing is an important way to prevent the spread of germs and infectious diseases.

C) "Caregivers should ensure that the children's toys are age-appropriate." Age-appropriate toys can prevent injury and ensure that children are able to use them safely and effectively.

E) "Caregivers should inspect the children's toys for small possibly inhalable parts." Small toys or parts can pose a choking hazard to young children and should be avoided. Regular inspections of toys can help to prevent accidents.

A) "Infants should always be placed to sleep on their sides." This advice is outdated and not recommended by current guidelines, which recommend that infants be placed on their backs to reduce the risk of Sudden Infant Death Syndrome (SIDS).

D) "Parents should be encouraged to avoid immunizations." Immunizations are an important way to protect infants and young children from serious diseases. Encouraging parents to avoid immunizations would be contrary to the goals of Healthy People 2020.

Quiz 17: Respiratory System