Deck 5: Assessing the Respiratory System

Question 1

Considering the patient's diagnosis of chronic obstructive pulmonary disease (COPD), the nurse assesses for signs and symptoms of hypoxia. What may alert the nurse to early signs and symptoms of hypoxia?

A) Change in mental status
B) Cyanosis
C) Tachycardia
D) Clubbing

Answer 1

Change in mental status

Question 2

Which assessment finding could indicate that the patient has lung cancer?

A) Clear sputum
B) Crackles upon auscultation
C) Eupnea
D) Fatigue

Answer 2

Fatigue

Question 3

The nurse notes clubbing of the nails during the physical assessment. Based on this data, which condition does the nurse suspect?

A) Iron deficiency anemia
B) Hypoglycemia
C) Hyperthyroidism
D) Polycythemia

Answer 3

Polycythemia

Question 4

Which is the best position to place the patient in to assess the lungs?

A) Supine
B) Prone
C) Fowler's
D) Side-lying

Question 5

The nurse assesses a patient for tactile fremitus. Which statement best defines tactile fremitus?

A) Palpable vibrations
B) Audible voice sounds
C) Audible breath sounds
D) Palpable chest movement

Question 6

Upon palpation of the patient's rib cage, the nurse notes a crackling sensation like crumpling cellophane. Which conclusion by the nurse is appropriate?

A) Fluid leaking into the surrounding tissue
B) Air leaking into the surrounding tissue
C) Infection of the lung
D) Cancer in the lung

Question 7

The nurse observes that the patient is using intercostal muscles for breathing. Adult males normally use which muscles for breathing?

A) Sternocleidomastoid
B) Thoracic
C) Abdominal
D) Cervical

Question 8

Upon inspection, the nurse notes that the patient has a barrel chest. What is the normal anteroposterior (AP)-to-lateral chest ratio?

A) 1:1
B) 1:2
C) 1:3
D) 1:4

Question 9

A respiratory rate of 20 for an adult patient is documented using which term?

A) Eupnea
B) Dyspnea
C) Bradypnea
D) Tachypnea

Question 10

Which respiratory disorders may be genetically linked?

A) Emphysema
B) Tuberculosis
C) Cor pulmonale
D) Pneumonia

Question 11

Pursed-lip breathing is most often seen in patients with which disease process?

A) Asthma
B) Pneumonia
C) COPD
D) Cor pulmonale

Question 12

Which is the reason for assessing a patient's chest excursion?

A) Monitoring for complete or partial airway obstruction
B) Monitoring for pleural effusion
C) Monitoring for pneumothorax
D) All of the above

Question 13

Inspection of the patient's chest reveals a wide costal angle. Which costal angle is expected for a healthy adult?

A) 45 degrees
B) 90 degrees
C) 160 degrees
D) 180 degrees

Question 14

Which definition best describes Kussmaul breathing, seen in diabetic ketoacidosis or lactic acidosis?

A) Progressively increasing, rapid, deep respiration that peaks and then gradually decreases
B) Rapid and deep respirations
C) Irregular rate and depth that alternates with periods of apnea
D) Regular breathing pattern followed by brief periods of apnea

Question 15

The nurse is assessing a patient diagnosed with emphysema. Which does the nurse anticipate when percussing over the patient's lungs?

A) Tympany
B) Dullness
C) Resonance
D) Hyperresonance

Question 16

An adult patient is admitted to the hospital with an acute exacerbation of chronic obstructive pulmonary disease (COPD). During the health history the patient admits dyspnea on exertion (DOE), cough, weight gain, and swollen ankles. Which of these findings is most frequently associated with respiratory disorders?

A) DOE
B) Cough
C) Weight gain
D) Swollen ankles

Question 17

While palpating the patient's chest, the nurse assesses the respiratory excursion. What is this technique used to assess?

A) Chest movement
B) Breath sounds
C) Lung vibrations
D) Voice sounds

Question 18

On auscultation of the patient's lung fields, crackles that do not clear with coughing are heard bilaterally at the bases. Which conclusion by the nurse is the most appropriate based on these assessment findings?

A) Collapsed alveoli popping open
B) Fluid in the lungs
C) Rales auscultated at the bases
D) All of the above

Question 19

The nurse asks the patient to repeat saying the number "99" several times as the rib cage is lightly palpated. Which is the nurse assessing for using this technique?

A) Fremitus
B) Egophony
C) Excursion
D) Crepitus

Question 20

Percussion over healthy lung tissue normally elicits which sound?

A) Tympany
B) Dullness
C) Resonance
D) Hyperresonance

Question 21

Which type of breath sound would the nurse expect to auscultate over most of the lung fields in a healthy patient?

A) Bronchial
B) Tracheal
C) Vesicular
D) Bronchovesicular

Question 22

Which physical assessment technique would be used to identify egophony?

A) Inspection
B) Palpation
C) Percussion
D) Auscultation

Question 23

Which physical assessment technique would be used to identify dullness?

A) Inspection
B) Palpation
C) Percussion
D) Auscultation

Question 24

The nurse is assessing an older adult patient who is admitted to the hospital with aspiration pneumonia of the right middle lobe. Which approaches will best facilitate assessment of the right middle lobe of the lung?

A) Anterior and lateral
B) Posterior and lateral
C) Posterior and anterior
D) Superior and inferior

Question 25

Which physical assessment technique would be used to identify sternal retraction?

A) Inspection
B) Palpation
C) Percussion
D) Auscultation

Question 26

Which physical assessment technique would best determine chest excursion?

A) Inspection
B) Palpation
C) Percussion
D) Auscultation

Question 27

Because the patient has pneumonia, the nurse assesses for abnormal voice sounds. The patient has clearer transmission of spoken voice sounds. This is an example of which type of voice sound?

A) Bronchophony
B) Whispered pectoriloquy
C) Egophony
D) Stridor

Question 28

Which standard view is typically inappropriate when conducting a respiratory assessment?

A) Anterior
B) Posterior
C) Lateral
D) Superior

Question 29

The nurse detects crackles when auscultating a patient's chest. Which statement accurately characterizes crackles?

A) Crackles are more predominant on inspiration.
B) Crackles are unaffected by coughing.
C) Crackles are heard over the large airways.
D) Crackles occur on inspiration and expiration.

Question 30

Which physical assessment technique would be used to identify rales?

A) Inspection
B) Palpation
C) Percussion
D) Auscultation

Question 31

The patient develops a pleural effusion, so a chest tube is inserted. The nurse detects crepitus at the insertion site. Which conclusion by the nurse is most appropriate?

A) Consolidation of the lung tissue
B) Pleural thickening
C) Air leakage into subcutaneous tissue
D) Obstructed airway

Question 32

The nurse is assessing a patient who is admitted with the diagnosis of pleuritis. Auscultation of the patient's thorax reveals a pleural friction rub. How can the nurse differentiate this sound from other abnormal breath sounds?

A) Rubs occur during inspiration and clear with coughing.
B) Rubs occur during expiration and produce a light popping sound.
C) Rubs occur during inspiration and may be heard anywhere.
D) Rubs occur during inspiration and expiration and are unaffected by coughing.

Question 33

Which physical assessment technique would be used to identify wheezing?

A) Inspection
B) Palpation
C) Percussion
D) Auscultation

Question 34

The nurse is assessing a patient diagnosed with consolidation pneumonia. Which type of breath sounds would the nurse expect to auscultate over the affected area?

A) Rales
B) Tracheal
C) Vesicular
D) Bronchial

Question 35

Which physical assessment technique would be used to identify tactile fremitus?

A) Inspection
B) Palpation
C) Percussion
D) Auscultation

Question 36

The nurse notes scattered rhonchi when auscultating the patient's chest. How do rhonchi differ from crackles?

A) Rhonchi are best heard in the periphery of the lungs.
B) Rhonchi are affected by coughing.
C) Rhonchi occur predominantly on inspiration.
D) Rhonchi have a rattle-like quality.

Question 37

When assessing for cyanotic changes, central cyanosis may be distinguished from peripheral cyanosis. Which location does the nurse use to assess for central cyanosis?

A) On the ear lobes
B) In the nailbeds
C) In the mucous membranes
D) On the fingers

Question 38

Which physical assessment technique would be used to determine the AP:lateral ratio?

A) Inspection
B) Palpation
C) Percussion
D) Auscultation