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Chapter 25 Assessment of Respiratory System
Community Health Nursing (University of Houston)
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Test Bank - Medical-Surgical Nursing: Assessment and Management of Clinical Problems 10e
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Chapter 25: Assessment of Respiratory System
Test Bank
MULTIPLE CHOICE
1. A patient with acute shortness of breath is admitted to the hospital. Which action should the nurse take
during the initial assessment of the patient?
a.
Ask the patient to lie down to complete a full physical assessment.
b.
Briefly ask specific questions about this episode of respiratory distress.
c.
Complete the admission database to check for allergies before treatment.
d.
Delay the physical assessment to first complete pulmonary function tests.
ANS: B
When a patient has severe respiratory distress, only information pertinent to the current episode is obtained,
and a more thorough assessment is deferred until later. Obtaining a comprehensive health history or full
physical examination is unnecessary until the acute distress has resolved. Brief questioning and a focused
physical assessment should be done rapidly to help determine the cause of the distress and suggest
treatment. Checking for allergies is important, but it is not appropriate to complete the entire admission
database at this time. The initial respiratory assessment must be completed before any diagnostic tests or
interventions can be ordered.
DIF: Cognitive Level: Apply (application) REF: 460
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
2. The nurse prepares a patient with a left-sided pleural effusion for a thoracentesis. How should the nurse
position the patient?
a.
Supine with the head of the bed elevated 30 degrees
b.
In a high-Fowlers position with the left arm extended
c.
On the right side with the left arm extended above the head
d.
Sitting upright with the arms supported on an over bed table
ANS: D
The upright position with the arms supported increases lung expansion, allows fluid to collect at the lung bases,
and expands the intercostal space so that access to the pleural space is easier. The other positions would
increase the work of breathing for the patient and make it more difficult for the health care provider performing
the thoracentesis.
DIF: Cognitive Level: Apply (application) REF: 470
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
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Test Bank - Medical-Surgical Nursing: Assessment and Management of Clinical Problems 10e
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3. A diabetic patients arterial blood gas (ABG) results are pH 7.28; PaCO2 34 mm Hg; PaO2 85 mm Hg;
HCO3 18 mEq/L. The nurse would expect which finding?
a.
Intercostal retractions
b.
Kussmaul respirations
c.
Low oxygen saturation (SpO2)
d.
Decreased venous O2 pressure
ANS: B
Kussmaul (deep and rapid) respirations are a compensatory mechanism for metabolic acidosis. The low pH and
low bicarbonate result indicate metabolic acidosis. Intercostal retractions, a low oxygen saturation rate, and a
decrease in venous O2 pressure would not be caused by acidosis.
DIF: Cognitive Level: Apply (application) REF: 457
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
4. On auscultation of a patients lungs, the nurse hears low-pitched, bubbling sounds during inhalation in the
lower third of both lungs. How should the nurse document this finding?
a.
Inspiratory crackles at the bases
b.
Expiratory wheezes in both lungs
c.
Abnormal lung sounds in the apices of both lungs
d.
Pleural friction rub in the right and left lower lobes
ANS: A
Crackles are low-pitched, bubbling sounds usually heard on inspiration. Wheezes are high-pitched sounds.
They can be heard during the expiratory or inspiratory phase of the respiratory cycle. The lower third of both
lungs are the bases, not apices. Pleural friction rubs are grating sounds that are usually heard during both
inspiration and expiration.
DIF: Cognitive Level: Understand (comprehension) REF: 465
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
5. The nurse palpates the posterior chest while the patient says 99 and notes absent fremitus. Which action
should the nurse take next?
a.
Palpate the anterior chest and observe for barrel chest.
b.
Encourage the patient to turn, cough, and deep breathe.
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Test Bank - Medical-Surgical Nursing: Assessment and Management of Clinical Problems 10e
c.
Review the chest x-ray report for evidence of pneumonia.
d.
Auscultate anterior and posterior breath sounds bilaterally.
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ANS: D
To assess for tactile fremitus, the nurse should use the palms of the hands to assess for vibration when the
patient repeats a word or phrase such as 99. After noting absent fremitus, the nurse should then auscultate the
lungs to assess for the presence or absence of breath sounds. Absent fremitus may be noted with pneumothorax
or atelectasis. The vibration is increased in conditions such as pneumonia, lung tumors, thick bronchial
secretions, and pleural effusion. Turning, coughing, and deep breathing is an appropriate intervention for
atelectasis, but the nurse needs to first assess breath sounds. Fremitus is decreased if the hand is farther from
the lung or the lung is hyperinflated (barrel chest).The anterior of the chest is more difficult to palpate for
fremitus because of the presence of large muscles and breast tissue.
DIF: Cognitive Level: Apply (application) REF: 464
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
6. A patient with a chronic cough has a bronchoscopy. After the procedure, which intervention by the nurse is
most appropriate?
a.
Elevate the head of the bed to 80 to 90 degrees.
b.
Keep the patient NPO until the gag reflex returns.
c.
Place on bed rest for at least 4 hours after bronchoscopy.
d.
Notify the health care provider about blood-tinged mucus.
ANS: B
Risk for aspiration and maintaining an open airway is the priority. Because a local anesthetic is used to
suppress the gag/cough reflexes during bronchoscopy, the nurse should monitor for the return of these reflexes
before allowing the patient to take oral fluids or food. Blood-tinged mucus is not uncommon after
bronchoscopy. The patient does not need to be on bed rest, and the head of the bed does not need to be in the
high-Fowlers position.
DIF: Cognitive Level: Apply (application) REF: 470
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
7. The nurse completes a shift assessment on a patient admitted in the early phase of heart failure. When
auscultating the patients lungs, which finding would the nurse most likely hear?
a.
Continuous rumbling, snoring, or rattling sounds mainly on expiration
b.
Continuous high-pitched musical sounds on inspiration and expiration
c.
Discontinuous, high-pitched sounds of short duration heard on inspiration
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d.
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A series of long-duration, discontinuous, low-pitched sounds during inspiration
ANS: C
Fine crackles are likely to be heard in the early phase of heart failure. Fine crackles are discontinuous, highpitched sounds of short duration heard on inspiration. Rhonchi are continuous rumbling, snoring, or rattling
sounds mainly on expiration. Course crackles are a series of long-duration, discontinuous, low-pitched sounds
during inspiration. Wheezes are continuous high-pitched musical sounds on inspiration and expiration.
DIF: Cognitive Level: Apply (application) REF: 467
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
8. While caring for a patient with respiratory disease, the nurse observes that the patients SpO2 drops from
93% to 88% while the patient is ambulating in the hallway. What is the priority action of the nurse?
a.
Notify the health care provider.
b.
Document the response to exercise.
c.
Administer the PRN supplemental O2.
d.
Encourage the patient to pace activity.
ANS: C
The drop in SpO2 to 85% indicates that the patient is hypoxemic and needs supplemental oxygen when
exercising. The other actions are also important, but the first action should be to correct the hypoxemia.
DIF: Cognitive Level: Apply (application) REF: 458
OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation
MSC: NCLEX: Physiological Integrity
9. The nurse teaches a patient about pulmonary function testing (PFT). Which statement, if made by the
patient, indicates teaching was effective?
a.
I will use my inhaler right before the test.
b.
I wont eat or drink anything 8 hours before the test.
c.
I should inhale deeply and blow out as hard as I can during the test.
d.
My blood pressure and pulse will be checked every 15 minutes after the test.
ANS: C
For PFT, the patient should inhale deeply and exhale as long, hard, and fast as possible. The other actions are
not needed with PFT. The administration of inhaled bronchodilators should be avoided 6 hours before the
procedure.
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Test Bank - Medical-Surgical Nursing: Assessment and Management of Clinical Problems 10e
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DIF: Cognitive Level: Apply (application) REF: 471
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
10. The nurse observes a student who is listening to a patients lungs who is having no problems with breathing.
Which action by the student indicates a need to review respiratory assessment skills?
a.
The student starts at the apices of the lungs and moves to the bases.
b.
The student compares breath sounds from side to side avoiding bony areas.
c.
The student places the stethoscope over the posterior chest and listens during inspiration.
d.
The student instructs the patient to breathe slowly and a little more deeply than normal through the
mouth.
ANS: C
Listening only during inspiration indicates the student needs a review of respiratory assessment skills. At each
placement of the stethoscope, listen to at least one cycle of inspiration and expiration. During chest
auscultation, instruct the patient to breathe slowly and a little deeper than normal through the mouth.
Auscultation should proceed from the lung apices to the bases, comparing opposite areas of the chest, unless
the patient is in respiratory distress or will tire easily. If so, start at the bases (see Fig. 26-7). Place the
stethoscope over lung tissue, not over bony prominences.
DIF: Cognitive Level: Apply (application) REF: 464
TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment
11. A patient who has a history of chronic obstructive pulmonary disease (COPD) was hospitalized for
increasing shortness of breath and chronic hypoxemia (SaO2 levels of 89% to 90%). In planning for discharge,
which action by the nurse will be most effective in improving compliance with discharge teaching?
a.
Start giving the patient discharge teaching on the day of admission.
b.
Have the patient repeat the instructions immediately after teaching.
c.
Accomplish the patient teaching just before the scheduled discharge.
d.
Arrange for the patients caregiver to be present during the teaching.
ANS: D
Hypoxemia interferes with the patients ability to learn and retain information, so having the patients caregiver
present will increase the likelihood that discharge instructions will be followed. Having the patient repeat the
instructions will indicate that the information is understood at the time, but it does not guarantee retention of
the information. Because the patient is likely to be distracted just before discharge, giving discharge
instructions just before discharge is not ideal. The patient is likely to be anxious and even more hypoxemic
than usual on the day of admission, so teaching about discharge should be postponed.
DIF: Cognitive Level: Apply (application) REF: 462
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Test Bank - Medical-Surgical Nursing: Assessment and Management of Clinical Problems 10e
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TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
12. A patient is admitted to the emergency department complaining of sudden onset shortness of breath and is
diagnosed with a possible pulmonary embolus. How should the nurse prepare the patient for diagnostic testing
to confirm the diagnosis?
a.
Start an IV so contrast media may be given.
b.
Ensure that the patient has been NPO for at least 6 hours.
c.
Inform radiology that radioactive glucose preparation is needed.
d.
Instruct the patient to undress to the waist and remove any metal objects.
ANS: A
Spiral computed tomography (CT) scans are the most commonly used test to diagnose pulmonary emboli, and
contrast media may be given IV. A chest x-ray may be ordered but will not be diagnostic for a pulmonary
embolus. Preparation for a chest x-ray includes undressing and removing any metal. Bronchoscopy is used to
detect changes in the bronchial tree, not to assess for vascular changes, and the patient should be NPO 6 to 12
hours before the procedure. Positron emission tomography (PET) scans are most useful in determining the
presence of malignancy, and a radioactive glucose preparation is used.
DIF: Cognitive Level: Apply (application) REF: 470
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
13. The nurse admits a patient who has a diagnosis of an acute asthma attack. Which statement indicates that
the patient may need teaching regarding medication use?
a.
I have not had any acute asthma attacks during the last year.
b.
I became short of breath an hour before coming to the hospital.
c.
Ive been taking Tylenol 650 mg every 6 hours for chest-wall pain.
d.
Ive been using my albuterol inhaler more frequently over the last 4 days.
ANS: D
The increased need for a rapid-acting bronchodilator should alert the patient that an acute attack may be
imminent and that a change in therapy may be needed. The patient should be taught to contact a health care
provider if this occurs. The other data do not indicate any need for additional teaching.
DIF: Cognitive Level: Apply (application) REF: 460
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
14. A patient with acute dyspnea is scheduled for a spiral computed tomography (CT) scan. Which information
obtained by the nurse is a priority to communicate to the health care provider before the CT?
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a.
Allergy to shellfish
b.
Apical pulse of 104
c.
Respiratory rate of 30
d.
Oxygen saturation of 90%
267
ANS: A
Because iodine-based contrast media is used during a spiral CT, the patient may need to have the CT scan
without contrast or be premedicated before injection of the contrast media. The increased pulse, low oxygen
saturation, and tachypnea all indicate a need for further assessment or intervention but do not indicate a need to
modify the CT procedure.
DIF: Cognitive Level: Apply (application) REF: 470
OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation
MSC: NCLEX: Physiological Integrity
15. The nurse analyzes the results of a patients arterial blood gases (ABGs). Which finding would require
immediate action?
a.
The bicarbonate level (HCO3) is 31 mEq/L.
b.
The arterial oxygen saturation (SaO2) is 92%.
c.
The partial pressure of CO2 in arterial blood (PaCO2) is 31 mm Hg.
d.
The partial pressure of oxygen in arterial blood (PaO2) is 59 mm Hg.
ANS: D
All the values are abnormal, but the low PaO2 indicates that the patient is at the point on the oxyhemoglobin
dissociation curve where a small change in the PaO2 will cause a large drop in the O2 saturation and a decrease
in tissue oxygenation. The nurse should intervene immediately to improve the patients oxygenation.
DIF: Cognitive Level: Apply (application) REF: eTable 25-1
OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity
16. When assessing the respiratory system of an older patient, which finding indicates that the nurse should
take immediate action?
a.
Weak cough effort
b.
Barrel-shaped chest
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c.
Dry mucous membranes
d.
Bilateral crackles at lung bases
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ANS: D
Crackles in the lower half of the lungs indicate that the patient may have an acute problem such as heart
failure. The nurse should immediately accomplish further assessments, such as oxygen saturation, and notify
the health care provider. A barrel-shaped chest, hyperresonance to percussion, and a weak cough effort are
associated with aging. Further evaluation may be needed, but immediate action is not indicated. An older
patient has a less forceful cough and fewer and less functional cilia. Mucous membranes tend to be drier.
DIF: Cognitive Level: Apply (application) REF: 467
OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity
17. A patient in metabolic alkalosis is admitted to the emergency department, and pulse oximetry (SpO2)
indicates that the O2 saturation is 94%. Which action should the nurse take next?
a.
Administer bicarbonate.
b.
Complete a head-to-toe assessment.
c.
Place the patient on high-flow oxygen.
d.
Obtain repeat arterial blood gases (ABGs).
ANS: C
Although the O2 saturation is adequate, the left shift in the oxyhemoglobin dissociation curve will decrease the
amount of oxygen delivered to tissues, so high oxygen concentrations should be given. Bicarbonate would
worsen the patients condition. A head-to-toe assessment and repeat ABGs may be implemented. However, the
priority intervention is to give high-flow oxygen.
DIF: Cognitive Level: Apply (application) REF: eTable 25-1
OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation
MSC: NCLEX: Physiological Integrity
18. After the nurse has received change-of-shift report, which patient should the nurse assess first?
a.
A patient with pneumonia who has crackles in the right lung base
b.
A patient with possible lung cancer who has just returned after bronchoscopy
c.
A patient with hemoptysis and a 16-mm induration with tuberculin skin testing
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d.
269
A patient with chronic obstructive pulmonary disease (COPD) and pulmonary function testing
(PFT) that indicates low forced vital capacity
ANS: B
Because the cough and gag are decreased after bronchoscopy, this patient should be assessed for airway
patency. The other patients do not have clinical manifestations or procedures that require immediate
assessment by the nurse.
DIF: Cognitive Level: Apply (application) REF: 470
OBJ: Special Questions: Prioritization; Multiple Patients
TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment
19. The laboratory has just called with the arterial blood gas (ABG) results on four patients. Which result is
most important for the nurse to report immediately to the health care provider?
a.
pH 7.34, PaO2 82 mm Hg, PaCO2 40 mm Hg, and O2 sat 97%
b.
pH 7.35, PaO2 85 mm Hg, PaCO2 45 mm Hg, and O2 sat 95%
c.
pH 7.46, PaO2 90 mm Hg, PaCO2 32 mm Hg, and O2 sat 98%
d.
pH 7.31, PaO2 91 mm Hg, PaCO2 50 mm Hg, and O2 sat 96%
ANS: D
These ABGs indicate uncompensated respiratory acidosis and should be reported to the health care provider.
The other values are normal or close to normal.
DIF: Cognitive Level: Apply (application) REF: 457
OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation
MSC: NCLEX: Physiological Integrity
20. The nurse assesses a patient with chronic obstructive pulmonary disease (COPD) who has been admitted
with increasing dyspnea over the last 3 days. Which finding is most important for the nurse to report to the
health care provider?
a.
Respirations are 36 breaths/minute.
b.
Anterior-posterior chest ratio is 1:1.
c.
Lung expansion is decreased bilaterally.
d.
Hyperresonance to percussion is present.
ANS: A
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Test Bank - Medical-Surgical Nursing: Assessment and Management of Clinical Problems 10e
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The increase in respiratory rate indicates respiratory distress and a need for rapid interventions such as
administration of oxygen or medications. The other findings are common chronic changes occurring in patients
with COPD.
DIF: Cognitive Level: Apply (application) REF: 460
OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity
21. Using the illustrated technique, the nurse is assessing for which finding in a patient with chronic
obstructive pulmonary disease (COPD)?
a.
Hyperresonance
b.
Tripod positioning
c.
Accessory muscle use
d.
Reduced chest expansion
ANS: D
The technique for palpation for chest expansion is shown in the illustrated technique. Reduced chest movement
would be noted on palpation of a patients chest with COPD. Hyperresonance would be assessed through
percussion. Accessory muscle use and tripod positioning would be assessed by inspection.
DIF: Cognitive Level: Understand (comprehension) REF: 464
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
22. Which action is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)?
a.
Listen to a patients lung sounds for wheezes or rhonchi.
b.
Label specimens obtained during percutaneous lung biopsy.
c.
Instruct a patient about how to use home spirometry testing.
d.
Measure induration at the site of a patients intradermal skin test.
ANS: B
Labeling of specimens is within the scope of practice of UAP. The other actions require nursing judgment and
should be done by licensed nursing personnel.
DIF: Cognitive Level: Apply (application) REF: 15
OBJ: Special Questions: Delegation TOP: Nursing Process: Assessment
MSC: NCLEX: Safe and Effective Care Environment
MULTIPLE RESPONSE
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Test Bank - Medical-Surgical Nursing: Assessment and Management of Clinical Problems 10e
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1. A patient is scheduled for a computed tomography (CT) of the chest with contrast media. Which assessment
findings should the nurse immediately report to the health care provider (select all that apply)?
a.
Patient is claustrophobic.
b.
Patient is allergic to shellfish.
c.
Patient recently used a bronchodilator inhaler.
d.
Patient is not able to remove a wedding band.
e.
Blood urea nitrogen (BUN) and serum creatinine levels are elevated.
ANS: B, E
Because the contrast media is iodine-based and may cause dehydration and decreased renal blood flow, asking
about iodine allergies (such as allergy to shellfish) and monitoring renal function before the CT scan are
necessary. The other actions are not contraindications for CT of the chest, although they may be for other
diagnostic tests, such as magnetic resonance imaging (MRI) or pulmonary function testing (PFT).
DIF: Cognitive Level: Analyze (analysis) REF: 470
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
OTHER
1. While listening to the posterior chest of a patient who is experiencing acute shortness of breath, the nurse
hears these sounds. How should the nurse document the lung sounds?
Click here to listen to the audio clip
a. Pleural friction rub
b. Low-pitched crackles
c. High-pitched wheezes
d. Bronchial breath sounds
ANS:
C
Wheezes are continuous high-pitched or musical sounds heard initially with expiration. The other responses are
typical of other adventitious breath sounds.
DIF: Cognitive Level: Understand (comprehension) REF: 461
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
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