The nurse is assessing an elderly client who is 2 days after ...

[drink]

The nurse is assessing an elderly client who is 2 days after abdominal surgery. The nurse recognizes that alterations in the respiratory system of the elderly put the client at risk for:
 
  1. Pulmonary embolus.
  2. Increased vital capacity.
  3. Upper respiratory infections.
  4. Rib fractures.

Question 2

The nurse uses inspection when performing a focused assessment of the respiratory system of a client complaining of cold symptoms. When the client asks the nurse why the nurse is watching the client breathe, the nurse should reply:
 
  1. I am checking the skin color of the chest.
  2. I am checking to make sure both sides expand equally.
  3. I am listening to hear air movement through the larynx.
  4. I am timing your inspirations.

[bblaney]

Answer to Question 1

Answer: 3

1. A pulmonary embolus would be related to alterations in the cardiovascular system.
2. Vital capacity is decreased.
3. Decreased mobility of the rib cage, weaker respiratory muscles, and loss of elasticity increase the risk for respiratory infections secondary to inability to clear secretions.
4. Rib fractures could occur with trauma.

Answer to Question 2

Answer: 2

1. The skin color on the chest will match the rest of the body.
2. Unequal chest expansion could indicate pathology.
3. The nurse listens to air in the upper airway by placing the stethoscope gently on the neck.
4. The nurse will not usually time inspiration unless the client has extreme lung pathology.