Deck 59: Assessment of the Respiratory System

Question 1

An older adult client says, "I need to get a shot so that I'll never get pneumonia again." The most helpful response by the nurse would be

A) "Immunization for pneumonia must be repeated every year."
B) "Most older people get flu shots, but they don't protect you from pneumonia."
C) "Pneumovax vaccine can protect you against one type of pneumonia."
D) "You cannot get a shot, or immunization, for pneumonia."

Answer 1

"Pneumovax vaccine can protect you against one type of pneumonia."

Question 2

The nurse clinician performing percussion of the chest on a client assesses a low-pitched, hollow sound over the middle lobe. The nurse would record this finding as

A) dull, and refer the client to an allergist.
B) hyperresonant, and refer to a physician for work-up.
C) resonant and document the finding, taking no other action.
D) tympany, and refer the client to radiology for a chest x-ray.

Answer 2

resonant and document the finding, taking no other action.

Question 3

A client has just returned from China and is concerned about possible respiratory disorders. The nurse would advise the client to have a screening to assess for exposure to

A) adult respiratory distress syndrome (ARDS).
B) histoplasmosis.
C) tuberculosis.
D) Valley fever.

Answer 3

tuberculosis.

Question 4

When a 49-year-old client tells the nurse he has smoked half a pack of unfiltered cigarettes a day since he was 19 years old, the nurse would record the pack-years as

A)15.
B)20.
C)25.
D)30

Question 5

When the nurse hears a high, hollow, drum-like sound while percussing the right chest of a young man with a right pneumothorax, the nurse would record this finding as

A) dullness.
B) flatness.
C) resonance.
D) tympany.

Question 6

The nurse reviews the results of the arterial carbon dioxide tension (PaCO₂) of a client with asthma to obtain information relative to the

A) contribution of gas exchange.
B) effectiveness of alveolar ventilation.
C) evidence of atelectasis.
D) presence of respiratory alkalosis.

Question 7

Evaluating the respiratory status of a 59-year-old man with vague complaints of respiratory problems, the nurse would know the assessment that is normal is

A) an inspiratory wheeze heard only with a stethoscope.
B) dyspnea with mild exertion.
C) reports of loud snoring by the client's spouse.
D) the absence of sputum production after coughing.

Question 8

The nurse would explain to a client that the most helpful test in the evaluation of a possible pulmonary embolus is

A) alveolar lavage.
B) bronchoscopy.
C) gallium scan.
D) ventilation-perfusion scan.

Question 9

The nurse preparing to assess a client for the presence of clubbing would instruct the client to

A) place both hands on a flat surface and splay the fingers.
B) place the nails of the ring fingers together.
C) sit upright and lean over the bedside table.
D) walk 50 feet up the hall as quickly as possible.

Question 10

The nurse would explain to a client with complaints of wheezing and chest tightness that wheezing occurs when

A) air is passing through a narrowed airway.
B) air is trapped in the alveoli.
C) an allergic reaction is taking place.
D) sputum production is increased.

Question 11

A 44-year-old man with active pulmonary tuberculosis is experiencing hemoptysis, which the nurse understands describes

A) bloody sputum.
B) chest pain.
C) constant cough.
D) dyspnea.

Question 12

The nurse preparing a client for a bronchoscopy would include information about its (Select all that apply)

A) ability to visualize gas exchange at the alveolar level.
B) limitation of not being able to take tissue biopsies.
C) therapeutic use to remove retained secretions.
D) usefulness in diagnosing tumors, inflammation, and strictures.

Question 13

The nurse auscultating the chest of a client with chronic bronchitis would expect to hear the characteristic adventitious breath sound of

A) bronchovesicular sounds in the bases.
B) crackles throughout the lung fields.
C) rhonchi on expiration.
D) wheezes on inspiration.

Question 14

A client with pulmonary disease appears more comfortable after respiratory therapy but still feels short of breath. To measure the client's respiratory improvement, the nurse would use a

A) Candle Scale.
B) pulmonary function test.
C) Treadmill test.
D) Visual Analogue Scale.

Question 15

Before drawing blood for an arterial blood gas (ABG), the nurse would perform a/an

A) Allen's test.
B) incentive spirometer assessment.
C) Schilling's test.
D) test for peripheral perfusion.

Question 16

A client says to the nurse, "It's hard for me to breathe; I feel winded all the time." The nurse would record this subjective feeling on the chart as

A) apnea.
B) dyspnea.
C) respiratory fatigue
D) tachypnea.

Question 17

A client being treated for emphysema has a chronic productive cough. The nurse would assess a characteristic feature of clients with long-term emphysema, which is

A) barrel chest.
B) broken vessels in the nose.
C) erythematous ear lobes.
D) pectus excavatum.