Question 1

During the assessment of a person's nasal cavities, the nurse notes watery nasal discharge and pale turbinates. What are these findings consistent with?

Accepted Answer

Watery nasal discharge and pale turbinates are consistent with allergies. Allergies can cause nasal congestion and a runny nose with clear discharge. The pale color of the turbinates may indicate inflammation or irritation from the allergy triggers.

Question 2

The nurse is preparing to auscultate a person's lungs. Which breath sounds should be considered abnormal? Select all that apply.

Accepted Answer

The lung sounds that should be considered abnormal are crackles and friction rub. Bronchial and bronchovesicular are normal breath sounds.

Question 3

Which of the following would the nasopharynx serve as a passage way for as it works in the respiratory system?

Accepted Answer

The nasopharynx serves as a passage way for air as it works in the respiratory system. It is not involved in the passage of food, debris, or other materials.

Question 4

A person's blood oxygen saturation level is 99% on room air. Through which of the following structures does the nurse realise that the oxygenated blood is transported to the heart ?

Accepted Answer

The pulmonary veins are the only structures listed that transport oxygenated blood from the lungs to the heart. The pulmonary arteries carry deoxygenated blood from the heart to the lungs, the jugular veins drain deoxygenated blood from the head and neck, and the superior vena cava returns deoxygenated blood from the upper body to the heart.

Question 5

Which of the following describes how the largest amount of carbon dioxide is transported?

Accepted Answer

The largest amount of carbon dioxide is transported as a bicarbonate ion in plasma, where it reacts with water to form carbonic acid. This reaction is catalyzed by carbonic anhydrase, and the resulting carbonic acid dissociates into bicarbonate ions and hydrogen ions. The bicarbonate ions are transported out of the red blood cells into the plasma, where they can be carried to the lungs to be exhaled. This accounts for about 70% of the carbon dioxide transport in the blood.

Question 6

During the palpation of a person'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.

Accepted Answer

A decrease in chest expansion on one side can be due to conditions like pneumothorax, pleural effusion, or pneumonia, which can restrict lung expansion. Emphysema typically causes bilateral changes rather than unilateral.

Question 7

Which of the following describes what happens to the respiratory rate when the level of carbon dioxide increases?

Accepted Answer

When the level of carbon dioxide increases in the body, it is detected by chemoreceptors in the brainstem. This triggers an increase in respiratory rate in order to remove the excess carbon dioxide through exhaling.

Question 8

The nurse notes that a person's respirations periodically stop while they are napping. How should these findings be documented?

Accepted Answer

Apnoea is the temporary cessation of breathing, which is the most appropriate choice to document the periodic cessation of respirations during napping. Cheyne-Stokes respirations are characterized by periods of deep breathing alternating with periods of apnoea, and tachypnoea and bradypnoea refer to rapid and slow breathing rates, respectively, which do not necessarily include periods of cessation of breathing.

Question 9

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

Accepted Answer

The apex of the lung is located at the highest point of the lung, which is near the clavicle. Therefore, the nurse should place the stethoscope near the right clavicle to assess the apex of the person's right lung.

Question 10

A person is diagnosed with a middle ear infection. Which part of the person's airway does the nurse realise is affected?

Accepted Answer

A middle ear infection, also known as otitis media, occurs in the space behind the eardrum, which is connected to the nasopharynx by the Eustachian tube. Therefore, the nasopharynx is the part of the person's airway affected by a middle ear infection. The oral cavity, oropharynx, and nasal cavity are not directly connected to the middle ear.

Question 11

Which of the following would be considered an important job of the paranasal sinuses?

Accepted Answer

The paranasal sinuses are air-filled spaces within the skull bones that help to lighten the weight of the skull while still providing strength and protection to the brain.

Question 12

During the assessment of a person's respiratory status, the nurse locates the manubrium and the body of the sternum. What is this also called?

Accepted Answer

The manubrium and body of the sternum are landmarks used to identify the angle of Louis, also known as the sternal angle. This is an important landmark for counting ribs and locating other structures in the chest. The mid-axillary line and intercostal spaces refer to other areas of the chest wall, while the xiphoid process is located at the bottom of the sternum.

Question 13

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

Accepted Answer

The larynx is located in the anterior part of the neck, and the Adam's apple (also known as the thyroid cartilage) is a protrusion that can be palpated in the midline of the neck, just above the level of the larynx. Therefore, identifying the Adam's apple can help the nurse locate the approximate position of the larynx. The first intercostal space is located between the first and second ribs and is not related to the larynx. The shoulder joint is located in the upper arm and is not related to the neck or larynx. The midclavicular line is an imaginary line that runs vertically down the middle of the clavicle and is not specific to the larynx location.

Question 14

The nurse percusses hyper-resonance over a person's lungs. What is this finding consistent with?

Accepted Answer

Hyper-resonance over the lungs typically signifies an increase in air, as seen in chronic asthma. Atelectasis may cause a dull percussion note, lobar pneumonia may cause a dull percussion note, and pleurisy may produce a friction rub on auscultation.

Question 15

A person is diagnosed with a fracture of one floating rib. Which of the following ribs is most likely fractured?

Accepted Answer

The floating ribs are the last two pairs of ribs (11 and 12) which are only attached to the vertebral column and not to the sternum. Therefore, the most likely rib to be fractured in this scenario is the 12th rib.

Question 16

During the assessment of a person's voice sounds, the nurse hears increased and clear sounds over the person's right lower lobe. What is this finding consistent with?

Accepted Answer

Increased and clear sounds on auscultation over a specific lung lobe suggests an increase in sound transmission caused by consolidation of lung tissue, which is often seen in lobar pneumonia. Atelectasis, pneumothorax, and emphysema would present with different findings on auscultation.

Question 17

During the assessment of a person's respirations, the nurse observes the expiration phase as being almost twice as long as the inspiration phase. What is this finding consistent with?

Accepted Answer

Normal respiration typically has a slightly longer expiration phase compared to inspiration phase, with a ratio of 1:2. Therefore, this finding is consistent with normal respiration.

Question 18

A person is demonstrating poor exhalation. The nurse realises that this person is at risk of developing which of the following?

Accepted Answer

Poor exhalation can lead to increased carbon dioxide levels in the body, as exhalation is the process by which carbon dioxide is eliminated from the body. This can lead to respiratory acidosis, a condition characterized by high levels of carbon dioxide in the blood and low pH. This can be dangerous and can lead to symptoms such as confusion, fatigue, and even coma. Therefore, it is important to address poor exhalation to prevent the risk of developing respiratory acidosis.

Question 19

During pulmonary function tests, a person is found to have approximately 500 mL of air that moves in and out of the lungs during normal quiet breathing. What is this known as?

Accepted Answer

The 500 mL of air that moves in and out of the lungs during normal quiet breathing is known as tidal volume. A is incorrect because total lung capacity is the total amount of air the lungs can hold, which includes the tidal volume, but also includes other volumes such as residual volume. C is incorrect because minute volume is the total amount of air that moves in and out of the lungs in one minute, which is calculated by multiplying the tidal volume by the respiratory rate. D is incorrect because the vital capacity is the maximum amount of air a person can forcefully exhale after taking a deep breath, which is usually greater than the tidal volume.

Question 20

During an assessment, a person begins to cough. The nurse realises that this means what?

Accepted Answer

Coughing is a reflex action to clear the airway when something other than air, such as food or liquid, enters the larynx.

Quiz 33: A Person-Centred Approach to Assessing the Respiratory System