Deck 34: Assessing the Respiratory System

Question 1

During a nap, the nurse notes that a patient's respirations periodically stop. This finding should be documented as which of the following?

A)tachypnea
B)bradypnea
C)apnea
D)atelectasis

Answer 1

apnea

Question 2

During the assessment of a patient's nasal cavities, the nurse notes watery nasal discharge and pale turbinates. These findings are consistent with which of the following?

A)allergies
B)infection
C)cocaine use
D)sinus infection

Answer 2

allergies

Question 3

A patient with a head cold is demonstrating a change in speech tone and volume. The nurse realizes that the sinus cavities are affected because of which of the following?

A)The patient is sneezing.
B)The patient is coughing.
C)The patient is afebrile.
D)The sinuses play a role in speech.

Answer 3

The sinuses play a role in speech.

Question 4

The nurse percusses hyperresonance over a patient's lungs. This finding is consistent with which of the following?

A)pneumonia
B)atelectasis
C)chronic asthma
D)pleural effusion

Question 5

During an assessment, a patient begins to cough. The nurse realizes that this means which of the following?

A)The patient has a cold.
B)The patient is nervous.
C)Something other than air was entering the larynx.
D)The patient is not fully conscious.

Question 6

Indicate with an "X" where bronchial lung sounds are auscultated.

Question 7

During the assessment of a patient, the nurse locates the approximate position of the larynx. This can be found by identifying which of the following?

A)the clavicle
B)the Adam's apple
C)the first rib
D)the shoulder joint

Question 8

During the assessment of a patient's respiratory status, the nurse locates the manubrium and the body of the sternum, which is also called which of the following?

A)Adam's apple
B)Angle of Louis
C)intercostal space
D)xiphoid process

Question 9

The nurse counts a patient's respirations at 30 per minute. From this finding, the nurse is concerned that the patient is which of the following?

A)developing pneumonia
B)attempting to expel increased carbon dioxide in the blood
C)going into respiratory arrest
D)in pain

Question 10

During the palpation of a patient's chest for expansion, the nurse notices a decrease in expansion of the right side. This finding is consistent with which of the following? Select all that apply.

A)emphysema
B)pneumonia
C)pleural effusion
D)heart failure
E)pneumothorax

Question 11

During pulmonary function tests, a patient is found to have approximately 500 mL of air that moves in and out of the lungs during normal quiet breathing. The nurse realizes that this finding is considered which of the following?

A)tidal volume
B)expiratory reserve volume
C)residual volume
D)vital capacity

Question 12

The nurse is preparing to auscultate a patient's lungs. Breath sounds that would be considered abnormal include which of the following? Select all that apply.

A)crackles
B)vesicular
C)bronchovesicular
D)wheezes
E)bronchial

Question 13

A patient's blood oxygen saturation level is 99% on room air. The nurse realizes that the oxygenated blood is transported to the heart through which of the following structures?

A)pulmonary arteries
B)pulmonary veins
C)bronchial arteries
D)bronchial veins

Question 14

The nurse observes a patient breathing through an open mouth. Which of the following functions is being bypassed by mouth breathing?

A)cooling the air
B)neutralizing the air
C)filtering the air
D)separating the air

Question 15

A trauma patient has no lung sounds in the oblique fissure, lower-left lobe and base of the lung. Place an "X" over the area the nurse is assessing.

Question 16

During the assessment of a patient's voice sounds, the nurse hears increased and clear sounds over the patient's right lower lobe. This finding is consistent with which of the following?

A)emphysema
B)LObar pneumonia
C)asthma
D)pleural effusion

Question 17

A patient is diagnosed with a middle ear infection. The nurse realizes that the portion of the patient's airway that is affected is which of the following?

A)nasopharynx
B)oropharynx
C)laryngopharynx
D)nares

Question 18

A patient is demonstrating poor exhalation. The nurse realizes that this patient is at risk for developing which of the following?

A)pleurisy
B)pulmonary edema
C)increased carbon dioxide levels
D)reduced oxygen capacity of red blood cells

Question 19

During the assessment of a patient's respirations, the nurse observes the expiration phase as being almost twice as long as the inspiration phase. This finding is consistent with which of the following?

A)chronic lung disease
B)heart failure
C)respiratory distress
D)normal respiration

Question 20

A patient is diagnosed with a low iron count. The nurse realizes that this patient might demonstrate signs of which of the following?

A)increased carbon dioxide in the blood
B)nausea
C)anxiety
D)poor tissue oxygenation

Question 21

Upon auscultation of the chest, the nurse reports to the preceptor what is heard. Which of the following statements should cause the preceptor to be most concerned?

A)"I heard crackles earlier, but now I am not able to hear anything."
B)"I hear wheezing in the right lobes, but clear on the left."
C)"There are course crackles that clear with coughing."
D)"The patient was clear, but now there are scattered wheezes bilaterally."

Question 22

$$\begin{array} { | l | l | } \hline \begin{array} { l } \text { Arterial Blood } \\\text { Gas }\end{array} & \text { Patient Results } \\\hline \mathrm { pH } & 7.28 \\\hline \mathrm { PaCO } _ { 2 } & 55 \mathrm { mmHg } \\\hline \mathrm { PaO } _ { 2 } & 75 \mathrm { mmHg } \\\hline \mathrm { HCO } _ { 3 } & 24 \mathrm { mEq } / \mathrm { L } \\\hline \mathrm { BE } & + 1 \mathrm { mEq } / \mathrm { L } \\\hline\end{array}$$

-A patient has these arterial blood gas (ABG) results (see above). In analyzing the data, the nurse recognizes the patient has which of the following?

A)metabolic acidosis
B)metabolic alkalosis
C)respiratory acidosis
D)respiratory alkalosis

Question 23

The nurse is conducting a health history on a patient with dyspnea. Place in order the sequence of gathering data. Click and drag the options below to move them up or down.

A)severity
B)associated symptoms
C)precipitating/relieving factors
D)timing and circumstances
E)characteristics and course
F)onset

Question 24

When preparing a patient for a pulmonary function test, which of the following should the nurse instruct the patient?

A)"Expect to be sedated for the test."
B)"Anti-nausea medication will be provided prior to the test."
C)"A nose clip will be worn during the test."
D)"Oxygen will be used for a while after the test."

Question 25

The nurse, instructing a patient on collecting a sputum sample, realizes that which is the best opportunity for the patient to provide the sample?

A)after a meal
B)upon awakening from a nap
C)before a meal
D)upon awakening in the morning

Question 26

A patient, admitted with probable emphysema, is scheduled for diagnostic tests to include which of the following to assess the patient's acid-base balance?

A)bronchoscopy
B)sputum studies
C)pulse oximetry
D)arterial blood gases (ABGs)

Question 27

The nurse would utilize capnography for which of the following patients?

A)intubated in the intensive care unit
B)in the emergency department with circumoral cyanosis
C)admitted for increased difficulty breathing with a history of chronic obstructive pulmonary disease
D)victim of a house fire

Question 28

The nurse administer oxygen to a patient who has lost a moderate amount of blood following a motor vehicle accident. The primary reason for this is to do which of the following?

A)Ease the work of breathing.
B)Compensate for the reduction in circulating oxygen.
C)Provide comfort.
D)Prevent shock.

Question 29

What factors related to aging can predispose an older adult to pneumonia? Select all that apply.

A)slower respiratory rate
B)less effective cough
C)immobility
D)increased pain response
E)fixed income

Question 30

The patient has these results on the PFTs. The nurse recognizes that the anatomic dead space volume is about _______. $$\begin{array} { | l | l | } \hline \begin{array} { l } \text { Pulmonary Function Test } \\\text { (PFT) }\end{array} & \text { Patient Results } \\\hline \text { Inspiratory Reserve Volume } & 3100 \mathrm {~mL} \\\hline \text { Tidal Volume } & 500 \mathrm {~mL} \\\hline \text { Expiratory Reserve Volume } & 1200 \mathrm {~mL} \\\hline \text { Residual Volume } & 1200 \mathrm {~mL} \\\hline\end{array}$$

A)100 mL
B)150 mL
C)200 mL
D)250 mL

Question 31

During a bronchoscopy, the nurse is to initially give 1.5 mg of midazolam hydrochloride (Versed) and another 1.5 mg of Versed in 2 minutes. Based on a concentration of 5 mg/mL, the nurse will draw up ______.

Question 32

Which of the following statements made by a patient with history of chronic respiratory disease indicates the need for further discharge teaching?

A)"As long as I take my medications and use my inhalers as prescribed, I should not have difficulty when traveling."
B)"I should avoid traveling to places at higher elevations as I will have increased difficulty breathing."
C)"To decrease my risk, any traveling I do should not be to places with recent outbreaks of respiratory illnesses."
D)"If I am acclimated to higher elevations, I should not experience problems with worsening symptoms."

Question 33

The nurse caring for a patient with a susceptibility to chronic pulmonary diseases realizes that this is most likely due to which of the following?

A)owned and worked a farm
B)worked in a hospital
C)worked as a air traffic controller
D)played in a band

Question 34

The nurse anticipates that a patient with multiple fractured ribs is at risk for which of the following?

A)decreased lung expansion
B)increased respiratory rate
C)prolonged expiratory phase
D)low arterial carbon dioxide level

Question 35

While preparing a patient for a bronchoscopy, the nurse ensures the suction equipment is available because of which of the following?

A)There is a high risk of a reaction to medications used for sedation.
B)Laryngospasm and respiratory distress could follow this test.
C)Suction equipment should always be available.
D)Pulmonary emboli is a complication following this test.

Question 36

The patient asks the nurse why she is having a positron emission tomography (PET) scan instead of a computed tomography (CT) scan. The nurse was present in the room when the physician discussed the test. What is the best response by the nurse?

A)"Your doctor prefers to order PET scans."
B)"Why are you concerned about this test?"
C)"PET scans have less radiation than CT scans."
D)"You will still need a CT scan also."

Question 37

The nurse, caring for an elderly patient, realizes that the patient is at risk for problems related to the volume of air remaining in the lungs because of which of the following?

A)Elasticity of lungs decreases with age.
B)Older adults have a more rapid respiratory rate.
C)There is a tightening of the diaphragm with age.
D)Intercostal muscles become weaker with age.

Question 38

$$\begin{array} { | l | l | } \hline \text { Pulmonary Function Test (PFT) } & \text { Patient Results } \\\hline \text { Inspiratory capacity } & 3600 \mathrm {~mL} \\\hline \text { Functional residual capacity } & 2600 \mathrm {~mL} \\\hline \text { Vital capacity } & 4600 \mathrm {~mL} \\\hline \text { Total lung capacity } & 5900 \mathrm {~mL} \\\hline\end{array}$$

-A patient has these PFT results (see above). The nurse knows the results are normal for which of the following?

A)a child
B)an adolescent
C)a middle-aged patient
D)an elderly patient

Question 39

Which of the following should the nurse determine before assessing a patient with a history of lower extremity edema?

A)Ask the patient for his or her position of comfort.
B)Auscultate breath sounds.
C)Inspect the skin for pallor.
D)Palpate the thorax.

Question 40

The nurse, providing discharge instruction to a patient with pulmonary disease, would determine that additional instruction is needed when which of the following statements has been made by the patient?

A)"If I notice a change in the shape of my chest, I should immediately call my healthcare provider."
B)"When I am assessing changes in my condition, I should notice increased use of abdominal muscles to exhale."
C)"It is important for me to report even subtle changes in energy and ability to complete daily tasks."
D)"I should keep records not only of my respiratory rate but also the depth and rhythm for a full minute."

Question 41

The nurse is planning a class for nursing assistants. Which should be included as causing interference with accurate pulse oximeter readings? Select all that apply.

A)ambient light
B)nail polish
C)inhalation injuries
D)arterial pulses
E)placement on cartilage

Question 42

If a patient is scheduled to have a magnetic resonance imaging scan (MRI), which information is most important for the nurse to obtain before the procedure?

A)whether or not the patient is wearing any metal such as a protective amulet
B)when the patient last ate or drank
C)whether or not the patient is allergic to shellfish
D)whether or not the patient has any loose teeth

Question 43

The nurse is caring for a patient who was admitted in respiratory distress. Which of the following is the nurse's priority action based on the data obtained from this ABG?

A)Place the patient on O₂ via mask.
B)Document and continue to monitor.
C)Call the healthcare provider to report the results.
D)Suction the patient.

Question 44

Nursing care following a bronchoscopy would include which of the following? Select all that apply. Select all that apply.

A)Instruct the patient to avoid eating and drinking for two hours after the test.
B)Report dark blood-tinged respiratory secretions to the physician.
C)Instruct the patient that a mild fever 24 hours following the test is expected.
D)Administer pain medications immediately following the procedure.
E)Instruct the patient on use of incentive spirometry to use following the procedure.

Question 45

The nurse wants to assess the apex of a patient's right lung. In which of the following locations should the nurse place the stethoscope to assess this patient?

A)intercostal space, sixth rib near the sternum
B)intercostal space, fourth rib near the axillary line
C)below the scapula
D)near the right clavicle

Question 46

A patient is admitted with a diagnosis of asbestos-related pulmonary disease. The nurse realizes that this diagnosis is most likely due to working in which environments? Select all that apply. Select all that apply.

A)construction
B)auto mechanics
C)shipyards
D)farming
E)food industry

Question 47

The nurse realizes that the symptom a patient with high altitude pulmonary edema is most likely to exhibit first would be which of the following?

A)change in the level of consciousness
B)polycythemia
C)vasoconstriction
D)vasodilation