Deck 28: Nursing Assessment: Respiratory System

Question 1

On auscultation of a patient's lungs,the nurse hears short,high-pitched sounds just before the end of inspiration in the right and left lower lobes.How should the nurse document this finding?

A) Inspiratory wheezes in both lungs
B) Crackles in the right and left lower lobes
C) Abnormal lung sounds in the bases of both lungs
D) Pleural friction rub in the right and left lower lobes

Answer 1

Inspiratory wheezes in both lungs

Question 2

While caring for a patient with respiratory disease,the nurse observes that the patient's SpO₂ drops from 94% to 85% when the patient ambulates in the hall.What does the nurse determine from this response?

A) Supplemental oxygen should be used when the patient exercises.
B) Arterial blood gas determinations should be done to verify the SpO₂.
C) This finding is a normal response to activity,and the patient should continue to be monitored.
D) The oximetry probe should be moved from the finger to the earlobe for an accurate SpO₂ during activity.

Answer 2

Supplemental oxygen should be used when the patient exercises.

Question 3

A patient with a chronic cough with blood-tinged sputum undergoes a bronchoscopy.Following the bronchoscopy,what should the nurse do?

A) Keep the patient on bed rest for 8 hours.
B) Keep the patient on nothing by mouth (NPO)status until the gag reflex returns.
C) Check vital signs every 15 minutes for 2 hours.
D) Encourage fluid intake to promote elimination of the contrast media.

Answer 3

Keep the patient on nothing by mouth (NPO)status until the gag reflex returns.

Question 4

On auscultation of a patient's lungs,the nurse hears short,low-pitched,'bubbling' sounds in the right and left lower lung areas.How should the nurse document this finding?

A) Inspiratory wheezes in both lungs
B) Crackles in the right and left lower lobes
C) Abnormal lung sounds in the bases of both lungs
D) Pleural friction rub in the right and left lower lobes

Question 5

An 80-year-old patient breathing room air has an arterial blood gas analysis.Which of the following results does the nurse interpret as normal?

A) pH 7.32,PaO₂ 85 mm Hg,PaCO₂ 55 mm Hg,and O₂ saturation 90%
B) pH 7.38,PaO₂ 75 mm Hg,PaCO₂ 40 mm Hg,and O₂ saturation 92%
C) pH 7.42,PaO₂ 80 mm Hg,PaCO₂ 33 mm Hg,and O₂ saturation 98%
D) pH 7.52,PaO₂ 90 mm Hg,PaCO₂ 30 mm Hg,and O₂ saturation 94%

Question 6

While caring for a patient who has a 30-pack-year history of smoking,the nurse recognizes that the patient most likely has decreased respiratory defences due to which of the following conditions?

A) Impaired cough reflex
B) Impaired mucociliary clearance
C) Impaired reflex bronchoconstriction
D) Impaired ability to filter particles from the air

Question 7

A patient with amyotrophic lateral sclerosis (ALS)is admitted to the hospital with dyspnea.During palpation of the patient's thorax,what would the nurse expect to find?

A) Diminished expansion
B) Asymmetrical expansion
C) Normal expansion of 2.5 cm
D) Unequal,diminished expansion

Question 8

A patient with chronic obstructive pulmonary disease (COPD)has a barrel chest.What would the nurse expect the results of a chest X-ray to reveal?

A) Fluid in the alveoli
B) Air in the pleural space
C) Overinflation of the alveoli with air
D) Consolidation of lung tissue with mucus and exudates

Question 9

When assessing the respiratory system of a 78-year-old patient,which of these findings indicates that the nurse should take immediate action?

A) Barrel-shaped chest
B) Weak cough effort
C) Audible crackles in the lower two thirds of the posterior chest
D) Hyperresonance across both sides of the chest

Question 10

In analyzing the results of a patient's blood gas analysis,the nurse will be most concerned about which of the following?

A) Arterial oxygen tension (PaO₂)of 60 mm Hg
B) Arterial oxygen saturation (SaO₂)of 91%
C) Arterial carbon dioxide (PaCO₂)of 47 mm Hg
D) Arterial bicarbonate level (HCO₃^-)of 27 mmol/L

Question 11

A patient is admitted with a metabolic acidosis of unknown origin.Based on this diagnosis,the nurse would expect the patient to have which one of the following?

A) Kussmaul's respirations
B) Slow,shallow respirations
C) A low oxygen saturation (SpO₂)
D) A decrease in PVO₂

Question 12

Which of the following is a normal partial pressure of oxygen value at sea level?

A) 60 mm Hg
B) 75 mm Hg
C) 90 mm Hg
D) 105 mm Hg

Question 13

A hypothermic patient is admitted to the emergency department,and pulse oximetry (SpO₂)indicates that the O₂ saturation is 95%.Which action should the nurse take next?

A) Complete a head-to-toe assessment.
B) Place the patient on high-flow oxygen.
C) Start rewarming the patient.
D) Obtain arterial blood gases.

Question 14

The nurse is observing a student who is auscultating a patient's lungs.Which action by the student indicates that the nurse should intervene?

A) The student compares breath sounds from side to side.
B) The student starts at the base of the posterior lung and moves to the apices.
C) The student places the stethoscope over the scapulae and then auscultates.
D) The student listens only over the posterior part of the chest.

Question 15

While assessing a patient with respiratory problems,what should the nurse specifically ask about?

A) Smoking habits
B) Alterations in sexual activity
C) The course of the patient's illness
D) Occupational exposure to heavy lifting

Question 16

When admitting a patient who has a pleural effusion,which technique will the nurse use to assess for tactile fremitus?

A) Percuss over the entire posterior chest.
B) Use the fingertips to assess for vibration.
C) Place the palms of the hands on the chest wall.
D) Auscultate while the patient says "ninety-nine."

Question 17

Which of the following is an age-related change in the respiratory system?

A) Increased elastic recoil of the lungs
B) Increase in chest wall compliance
C) Increase in anteroposterior diameter
D) Increase in functional alveoli

Question 18

A patient in severe respiratory distress is admitted to the medical unit at the hospital.During the admission assessment of the patient,what should the nurse do?

A) Perform a comprehensive health history with the patient to determine the extent of prior respiratory problems.
B) Complete a full physical examination to determine the effect of the respiratory distress on other body functions.
C) Delay any physical assessment of the patient,and ask family members about the patient's history of respiratory problems.
D) Perform a physical assessment of the respiratory system,and ask specific questions related to this episode of respiratory distress.

Question 19

The physician performs a thoracentesis on a patient with a right pleural effusion.In preparing the patient for the procedure,how should the nurse position the patient?

A) Supine with the head of the bed elevated 45 degrees
B) On his left side with his right arm extended above his head
C) Sitting upright with his arms supported on an overbed table
D) On his left side in the Trendelenburg's position with both arms extended

Question 20

While auscultating a patient's chest as the patient takes a deep breath,the nurse hears loud,high-pitched,"blowing" sounds at both lung bases.How will the nurse document these sounds?

A) Adventitious sounds
B) Abnormal sounds
C) Vesicular sounds
D) Normal sounds

Question 21

Which of the following is an early symptom of inadequate oxygenation?

A) Dyspnea at rest
B) Hypotension
C) Tachypnea
D) Cyanosis

Question 22

A patient is admitted to the emergency department complaining of sudden-onset shortness of breath and is diagnosed with a possible pulmonary embolus.To confirm the diagnosis,the nurse will anticipate preparing the patient for which of the following?

A) Chest X-ray
B) Ventilation-perfusion scan
C) Bronchoscopy
D) Positron emission tomography scan

Question 23

Which of the following is a measure of the elasticity of the lung?

A) Inspiration
B) Compliance
C) Elastic recoil
D) Oxygen-hemoglobin dissociation curve

Question 24

When performing an assessment of the patient's respiratory system,the nurse uses the following illustrated technique to evaluate which of the following respiratory functions?

A) Chest expansion
B) Tactile fremitus
C) Accessory muscle use
D) Diaphragmatic excursion