Deck 18: Pulmonary Clinical Assessment

Question 1

Why would the nurse perform an inspection of the oral cavity during a complete pulmonary assessment?

A) To provide evidence of hypoxia
B) To provide evidence of dyspnea
C) To provide evidence of dehydration
D) To provide evidence of nutritional status

Answer 1

To provide evidence of hypoxia

Question 2

A patient is admitted to the critical care unit with acute respiratory failure secondary to chronic obstructive pulmonary disease.The patient has a 15-year history of emphysema and bronchitis.On inspection,the nurse observes that the patient is experiencing air trapping.While auscultating the chest,the nurse notes the presence of coarse,rumbling,low-pitched sounds in the right middle and lower lobes.On further inspection of the patient,the nurse observes that his fingers appear discolored.This is a result of

A) clubbing.
B) central cyanosis.
C) peripheral cyanosis.
D) chronic tuberculosis.

Answer 2

peripheral cyanosis.

Question 3

A patient presents with chest trauma from an MVA.Upon assessment,the nurse documents that the patient is complaining of dyspnea,shortness of breath,tachypnea,and tracheal deviation to the right.In addition,the client's tongue is blue-gray.Based on the following data,what would the nurse would expect to find?

A) PaO? of 88 and PCO? of 55
B) Absent breath sounds in all right lung fields
C) Absent breath sounds in all left lung fields
D) Diminished breath sounds in all fields

Answer 3

Absent breath sounds in all left lung fields

Question 4

A patient is admitted to the unit in respiratory distress secondary to pneumonia.The nurse knows that obtaining a history is very important.What is the appropriate intervention at this time for obtaining this data?

A) Collect an overview of past medical history, present history, and current health status.
B) Do not obtain any history at this time.
C) Curtail the history to just a few questions about the client's chief complaint and precipitating events.
D) Complete the history and then provide measures to assist the client to breathe easier.

Question 5

Which of the following lung sounds would be most likely heard in a client experiencing an asthma attack?

A) Coarse rales
B) Pleural friction rub
C) Fine crackles
D) Expiratory wheezes

Question 6

A client just involved in a motor vehicle accident has sustained blunt chest trauma as part of his injuries.The nurse assessment reveals absent breath sounds in the left lung field.A left-sided pneumothorax is suspected and is further validated when assessment of the trachea reveals

A) a shift to the right.
B) a shift to the left.
C) no deviation.
D) subcutaneous emphysema.

Question 7

Which of the following is an example of a disorder with increased tactile fremitus?

A) Emphysema
B) Pleural effusion
C) Pneumothorax
D) Pneumonia

Question 8

Which of the following describes the major difference between tachypnea and hyperventilation?

A) Tachypnea has increased rate; hyperventilation has decreased rate.
B) Tachypnea has decreased rate; hyperventilation has increased rate.
C) Tachypnea has increased depth; hyperventilation has decreased depth.
D) Tachypnea has decreased depth; hyperventilation has increased depth.

Question 9

While conducting a physical assessment,you note that the patient's breathing is rapid and shallow.This type of breathing pattern is known as

A) hyperventilation.
B) tachypnea.
C) obstructive breathing.
D) bradypnea.

Question 10

The adventitious breath sounds that sound like popping in the small airways or alveoli are

A) sonorous wheezes.
B) crackles.
C) sibilant wheezes.
D) pleural friction rubs.

Question 11

A patient is admitted to the critical care unit with acute respiratory failure secondary to COPD.The patient has a 15-year history of emphysema and bronchitis.On inspection,the nurse observes that the patient is experiencing air trapping.While auscultating the chest,the nurse notes the presence of coarse,rumbling,low-pitched sounds in the right middle and lower lobes.On percussion of the lung fields,a patient with emphysema will predictably exhibit which tone?

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

Question 12

The use of touch to judge the character of the body surface and underlying organs is known as

A) inspection.
B) palpation.
C) percussion.
D) auscultation.

Question 13

Diminished to absent breath sounds on the right side,tracheal deviation to the left side,and asymmetrical chest movement are indicative of which of the following disorders?

A) Tension pneumothorax
B) Pneumonia
C) Pulmonary fibrosis
D) Atelectasis

Question 14

Voice sounds such as bronchophony,egophony,and whispering pectoriloquy are increased in

A) pneumonia with consolidation.
B) pneumothorax.
C) asthma.
D) bronchiectasis.

Question 15

A patient is admitted to the critical care unit with acute respiratory failure.Upon auscultation,the health care provider hears creaking,leathery,coarse breath sounds in the lower anterolateral chest area during inspiration and expiration.The nurse suspects that the patient has a(n)

A) emphysema.
B) atelectasis.
C) pulmonary fibrosis.
D) pleural friction rub.

Question 16

A patient is admitted to the critical care unit with acute respiratory failure secondary to COPD.The patient has a 15-year history of emphysema and bronchitis.On inspection,the nurse notes that the patient is experiencing air trapping.While auscultating his chest,you note the presence of coarse,rumbling,low-pitched sounds in the right middle and lower lobes.Which of the following best describes the patient's breathing pattern?

A) Deep sighing breaths without pauses
B) Rapid, shallow breaths
C) Normal breathing pattern interspersed with forced expirations
D) Irregular breathing pattern with both deep and shallow breaths

Question 17

Diaphragmatic excursion is a measurement of the difference in the level of the diaphragm on inspiration and expiration determined by percussion.It is increased in

A) atelectasis and emphysema.
B) hepatomegaly and ascites.
C) atelectasis and paralysis.
D) pneumonia and pneumothorax.

Question 18

Normal anteroposterior (AP)diameter ranges from 1:2 to 5:7.An increase in AP diameter of the chest that is characterized by displacement of the sternum forward and the ribs outward is indicative of

A) a funnel chest.
B) a pigeon breast.
C) a barrel chest.
D) Harrison's groove.

Question 19

Auscultation of the anterior chest should be performed using which of the following sequences?

A) Right side, top to bottom, then left side, top to bottom
B) Left side, top to bottom, then right side, top to bottom
C) Side to side, bottom to top
D) Side to side, top to bottom

Question 20

On assessment of a client,you note fremitus over the trachea but not in the lung periphery.You know that this most likely represents

A) bilateral pleural effusion.
B) bronchial obstruction.
C) a normal finding.
D) apical pneumothorax.

Question 21

Which of the following regarding the client history will assist the nurse in developing the plan of management?

A) Provides direction for the rest of the assessment
B) Exposes key clinical manifestations
C) Aids in developing the plan of care
D) The degree of the client's distress determines the extent of the interview
E) Determines length of stay in the hospital setting

Question 22

The creation of sound waves across the body surface to determine abnormal densities is known as

A) inspection.
B) palpation.
C) percussion.
D) auscultation.

Question 23

Which of the following conditions will commonly reveal breath sounds with inspiration greater than expiration on assessment?
1)Normal lung
2)Bronchiectasis
3)Emphysema
4)Acute bronchitis
5)Diffuse pulmonary fibrosis
6)Consolidating pneumonia

A) 1, 2, 5
B) 3, 5, 6
C) 2, 3, 4
D) 1, 2, 4

Question 24

The use of observation for assessment is known as

A) inspection.
B) palpation.
C) percussion.
D) auscultation.

Question 25

Deviation of the trachea occurs in which of the following conditions?

A) Pneumothorax
B) Pulmonary fibrosis
C) Chronic obstructive pulmonary disease
D) Emphysema
E) Pleural effusion