Question 1

During the respiratory assessment of a client the nurse wishes to locate the angle of Louis.This structure can be identified by using which of the following landmarks?

Accepted Answer

The angle of Louis, also known as the sternal angle, is a bony landmark on the sternum. It is located at the junction between the manubrium and the body of the sternum, making the sternum the correct landmark to locate the angle of Louis.

Question 2

The client aspirated a pea during a meal.The healthcare provider noted that the pea was in the bronchus.Draw an arrow to the most likely site of the pea.

Accepted Answer

The answer of The client aspirated a pea during a...

Question 3

The nurse documents that the client's respirations are shallow and rapid.The client's respiratory rate is 30 per minute.From this finding,the nurse is concerned the client is:

Accepted Answer

Shallow and rapid respirations can be a sign of anxiety, especially when combined with a respiratory rate of 30 per minute. This can be the body's response to the "fight or flight" response to stress. While fatigue can cause shallow respirations, it is less likely to cause rapid respirations. Boredom would not typically cause shallow and rapid respirations.

Question 4

The client was brought to the Emergency Department.The nurse administered a breathing treatment for the client earlier.The nurse is preparing the client for a procedure.The nurse notes that the client is breathing in a shallow manner and the client's hands are trembling.Which of the following actions will help decrease the client's level of anxiety?

Accepted Answer

Explaining procedures in a calm and reassuring voice can help reduce anxiety in the client. Requesting the immediate presence of the healthcare provider or postponing the procedure may not be necessary at this time. Providing oxygen may be beneficial for the client's shallow breathing but may not address the underlying cause of the anxiety.

Question 5

Draw an arrow that points to the right anterior axillary line (AAL).

Accepted Answer

The answer of Draw an arrow that points to the...

Question 6

During the assessment of a client's respiratory system,the nurse determines that the client's expiration phase is the same length as the inspiration phase.The client's respiratory rate is 14 per minute.The nurse would document this finding as:

Accepted Answer

This finding is normal as the inspiration and expiration phases are of equal length and the respiratory rate is within the normal range (12-20 breaths per minute). Obstructive breathing would involve difficulty exhaling, and respiratory distress would be characterized by increased respiratory effort or shortness of breath. Bradypnea refers to a slower than normal respiratory rate.

Question 7

The nurse is preparing to auscultate a client's lungs.Which of the following breath sounds would be considered abnormal?

Accepted Answer

Crackles and wheezes are both abnormal breath sounds that indicate lung pathology. Crackles are usually heard in clients with pulmonary edema or interstitial lung disease, while wheezes are associated with conditions such as asthma, bronchitis, or COPD. Vesicular, bronchovesicular, and bronchial breath sounds are all normal and should be present in healthy individuals.

Question 8

While palpating respiratory expansion on a client in the emergency room the nurse notes movement on only one side of the chest.Which of the following conditions may produce this finding?

Accepted Answer

Atelectasis, lobar pneumonia, and pleural effusion can all lead to unilateral chest movement due to the localized nature of these conditions affecting lung expansion on one side. Atelectasis involves the collapse of lung tissue, lobar pneumonia is an infection confined to one or more lobes of the lung, and pleural effusion is the accumulation of fluid in the pleural space, all of which can restrict lung expansion on the affected side.

Question 9

The nurse is preparing to assess the client's respiratory system.Rank in order according to how the nurse should proceed.
A)Auscultation 
B)Inspection 
C)Percussion 
D)Client survey 
E)Palpation

Accepted Answer

The answer of The nurse is preparing to assess the...

Question 10

Draw an arrow to the area where tracheal breath sounds can be auscultated.

Accepted Answer

The answer of Draw an arrow to the area where...

Question 11

The nurse percusses the lungs and determines that there is an area of hyperresonance.This finding is consistent with which of the following conditions?

Accepted Answer

Hyperresonance on percussion indicates too much air in the lung tissue, which is consistent with a pneumothorax (collapsed lung). In pneumonia, there is usually dullness to percussion due to consolidation of lung tissue. Atelectasis may produce dullness or flatness to percussion. Pleural effusion often results in a flatness to percussion.

Question 12

The nurse wants to assess the apex of a client's right lung.Which of the following locations should the nurse place the stethoscope to assess this area on the client?

Accepted Answer

The apex of the lung is located at the top portion of the lung, just under the clavicle. Therefore, to assess the apex of the right lung, the stethoscope should be placed near the right clavicle.

Question 13

The nurse is assessing the client.The nurse hears low-pitched,continuous respiratory sounds that have a snoring quality while auscultating the client's lungs.The nurse would correctly document these findings as which of the following?

Accepted Answer

Rhonchi are low-pitched, continuous sounds with a snoring or moaning quality. They are usually heard on auscultation in clients with airway obstruction or secretions in the large airways. Rales and crackles are high-pitched, discontinuous sounds heard during inspiration and wheezes are high-pitched, continuous sounds heard during expiration.

Question 14

While assessing the client,the nurse notes that the client has a moist cough.The nurse would include which of the following questions in the focused interview?

Accepted Answer

The presence of a moist cough indicates that the client may be coughing up mucus or phlegm. Therefore, it would be important to ask if the client is experiencing this symptom to gather more information about their condition. Options A and B are more general questions and option C is more specific to wheezing, which may not necessarily be present in the client's case.

Question 15

While the client sleeps,the nurse notes that the client's respirations periodically stop.This finding would be documented as:

Accepted Answer

Apnea is the cessation of breathing for a period of time, which is what the nurse is observing in the client. Tachypnea is rapid breathing, bradypnea is slow breathing, and atelectasis refers to the collapse of a portion of the lung, none of which describe the issue observed in the client.

Question 16

During the assessment of a client's voice sounds,the nurse hears louder sounds over the client's right lower lobe.This finding would be consistent with:

Accepted Answer

Lobar pneumonia typically presents with increased breath sounds over the affected lobe, leading to louder sounds on auscultation. Atelectasis, asthma, and pleural effusion may all cause changes in lung sounds, but would not necessarily result in louder sounds over a specific lobe.

Question 17

The nurse is assessing the client's respiratory pattern and notes periods of deep breathing alternating with periods of apnea.Which of the following terms would the nurse use to document this finding?

Accepted Answer

Cheyne-Stokes breathing is characterized by periods of deep breathing alternating with periods of apnea. It is commonly seen in clients with neurological or cardiac conditions.

Question 18

The nurse is assessing a client with a severe left pleural effusion.Which of the following findings are expected?

Accepted Answer

The answer of The nurse is assessing a client with...

Question 19

The nursing instructor is observing a student nurse assess the client's respiratory system.The student demonstrates proper technique for auscultation when moving the stethoscope:

Accepted Answer

Auscultation of the lungs should be done from side to side to compare corresponding areas on each side for symmetry and to detect any abnormal sounds.

Question 20

The nurse is assessing the client's respiratory system.Which of the following methods will result in the most accurate assessment of the client's respiratory rate?

Accepted Answer

Counting the respirations in an unobtrusive manner without informing the client will result in the most accurate assessment, as the client may alter their breathing pattern if they know they are being observed. Placing a hand on the client's chest to count respirations accurately may be intrusive and may also alter the client's breathing pattern. Counting only audible respirations may result in an inaccurate assessment if the client is breathing quietly or has shallow breaths. Informing the client that respirations are being counted may make the client self-conscious and may alter their breathing pattern.

Quiz 15: Respiratory System