Deck 25: Nursing Assessment of the Patient With Respiratory Disorders

Question 1

The nurse is conducting a health history interview with a patient who has severe respiratory disease. The nurse asks specific questions about how the patient performs oral hygiene. What is the rationale for this questioning?

A) Oral infections can result in pulmonary infections.
B) The ability to perform good oral hygiene reflects an ability to hold one's breath for several seconds.
C) Respiratory illness is associated with an increased risk for dental caries.
D) People who perform good oral hygiene typically also perform good hand hygiene.

Answer 1

Oral infections can result in pulmonary infections.

Question 2

A nurse researcher is planning a study regarding occupational exposure to asbestos and the development of asbestos-related pulmonary disease. The researcher should look to workers from which occupations as commonly having this exposure?.Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply.

A) Firefighters
B) Auto mechanics
C) Those involved in new home construction
D) Teachers
E) Cooks

Answer 2

Firefighters
Auto mechanics

Question 3

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 condition?.Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply.

A) Emphysema
B) Pneumothorax
C) Flail chest
D) Heart failure
E) Influenza

Answer 3

Pneumothorax
Flail chest

Question 4

A patient with a preexisting pulmonary illness is being seen in the clinic for a routine assessment. The patient says, "My family and I are going skiing for our next vacation." What information should the nurse provide?

A) "Going to high altitudes is not a good idea for your health."
B) "You should be watchful for any respiratory problems while you are there."
C) "You should go to the seashore instead."
D) "Be certain to fly directly to the resort if possible."

Question 5

The nurse is preparing to auscultate a patient's lungs. Which breath sounds would the nurse consider abnormal?.Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply.

A) Crackles
B) Vesicular breath sounds
C) Bronchovesicular breath sounds
D) Wheezes
E) Bronchial breath sounds

Question 6

During an assessment, a patient begins to cough. How would the nurse evaluate this finding?

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 7

After auscultating a patient's chest, the nurse reports the findings to the preceptor. Which statement would indicate the need for immediate reassessment by the preceptor?

A) "I heard coarse crackles earlier, but now they sound finer."
B) "I heard wheezing earlier, but now I don't hear it."
C) "There are coarse crackles that clear with coughing."
D) "The patient was clear, but now there are scattered wheezes bilaterally."

Question 8

A patient is diagnosed with a low iron count. The nurse would be alert for which finding associated with this condition?

A) Increased carbon dioxide in the blood
B) Nausea
C) Anxiety
D) Poor tissue oxygenation

Question 9

A patient from Southeast Asia presents to the clinic with complaints of shortness of breath. The patient says, "I tried to coin my wind illness, but it did not work." Which assessment finding would the nurse expect?

A) The patient is wearing an amulet shaped like a dragon.
B) The patient has burns on the inside of the nose and mouth.
C) The patient is pale from blood loss.
D) The patient has small scrapes across the back and chest.

Question 10

The nurse administers oxygen to a patient who has lost a moderate amount of blood following a motor vehicle accident. What is the primary rationale for this nursing action?

A) To ease the work of breathing
B) To compensate for the reduction in circulating oxygen
C) To provide comfort
D) To prevent shock

Question 11

A review of a patient's medical record reveals that the patient is using accessory muscles to aid breathing. Which muscle groups would the nurse expect to see in use?.Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply.

A) Abdominals
B) Scalene
C) Brachialis
D) Trapezius
E) Sternocleidomastoid

Question 12

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

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 13

The patient says, "I think I am allergic to something in my house. I feel better when I am away for a few days." What should the nurse suggest?

A) "You might want to keep your dog outside."
B) "You might want to consider having allergy testing done."
C) "You should remove dust by vacuuming your house every day and getting rid of your drapes and decorative pillows."
D) "You should consider having your home professionally cleaned."

Question 14

The nurse knows that the caregiver of a patient with a respiratory illness understands discharge teaching when the caregiver makes which statement?

A) "I can expect to hear adventitious sounds only in the mornings; the rest of the day, breath sounds should be normal."
B) "If I hear extra sounds during a deep breath, I know I am hearing adventitious sounds."
C) "Adventitious sounds may be heard during inspiration or expiration because of secretions or inflammation."
D) "I will know I am hearing adventitious breath sounds if I hear any sounds when I listen over the lower chest."

Question 15

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

A) Decreased lung expansion
B) Increased respiratory rate
C) Prolonged expiratory phase
D) Low arterial carbon dioxide level

Question 16

A patient with pneumonia is experiencing shunt ventilation. The nurse plans care for the patient based on which considerations?.Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply.

A) Shunt ventilation is the normal state for a patient who has pneumonia.
B) Blood flow to the alveoli is compromised.
C) Blood is flowing past the alveoli but is not being oxygenated.
D) Ventilation is inadequate at the alveolar level.
E) Hypoxia may occur if the unaffected lung cannot compensate.

Question 17

A patient admitted with probable emphysema is scheduled for diagnostic tests. Which test would assess the patient's acid-base balance?

A) Bronchoscopy
B) Sputum studies
C) Pulse oximetry
D) Arterial blood gases (ABGs)

Question 18

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

Question 19

The patient has respiratory difficulty due to changes in anatomic dead space. The nurse plans interventions based on changes in which physiological process?

A) Beginning of the gas exchange process
B) Neutralizing the air
C) Filtering the air
D) Separating the air

Question 20

The nurse is planning a class for unlicensed assistive personnel. Which factors should the nurse describe as causing interference with accurate pulse oximeter readings?.Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply.

A) Ambient light
B) Nail polish
C) Inhalation injuries
D) Arterial pulse deficit
E) Sensor placement on the ear

Question 21

During auscultation of the thorax, the nurse hears a low-pitched creaking sound. What should be the nurse's next action?

A) Have the patient cough to attempt to clear the sound.
B) Have the patient turn to the left side.
C) Collaborate with the physician regarding a chest X-ray.
D) Ask the patient to hold her breath.

Question 22

A review of a patient's medical record reveals a 70-pack-year smoking history. The patient says he smokes two packs of cigarettes every day. The nurse calculates that this patient has been smoking for ______ years.

Question 23

A patient has been admitted for exacerbation of a chronic pulmonary disease. The nurse would assign the nursing diagnosis Activity Intolerance when which assessment is made?

A) The patient's heart rate increases by 20 beats per minute when she ambulates to the bathroom in her hospital room.
B) The patient's husband reports that she sits in a recliner chair most of the day.
C) The patient complains of cramping in her legs at night.
D) The patient's ankles demonstrate 3+ edema bilaterally.

Question 24

A patient is admitted after falling down a flight of stairs. The nurse notes that the patient's larynx is slightly left of center. The nurse should assess for which conditions?.Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply.

A) Right heart failure
B) Left hemothorax
C) Right pneumothorax
D) Right hemothorax
E) Central pneumothorax

Question 25

The nurse is assessing a patient for pedal edema. If using the correct technique, the nurse will depress the tissue for _____ seconds.

Question 26

To establish the location of a respiratory sound, the nurse uses standard landmarks. The nurse locates the second rib as adjacent to which structure?

A) Supersternal notch
B) Sternal angle
C) Costal margin
D) Xiphoid process

Question 27

A parent has just started using a "red, yellow, green" peak flow meter to monitor his young son's pulmonary disease at home. The parent calls the clinic and reports that the last two results have been in the red zone. What advice should the nurse offer this parent?

A) "Rinse the meter out with warm salt water and repeat the test."
B) "Bring your son and the meter to the clinic for evaluation."
C) "Don't bother using the meter until I can check your technique at next week's appointment."
D) "These are the results we hope to see, so it sounds like you are doing a good job managing your son's illness."