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Chapter 25 - resp
VSNG Med Surg 1 (Austin Community College District)
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Chapter 25: Assessment: Respiratory System
Question 1 of 21
When auscultating the patient’s lower lungs, the nurse hears low-pitched sounds similar to
blowing through a straw under water on inspiration. How should the nurse document these
sounds?
Correct Answer:
Coarse crackles
Rationale:
Coarse crackles are a series of long-duration, discontinuous, low-pitched sounds caused by air passing
through an airway intermittently occluded by mucus, an unstable bronchial wall, or a fold of mucosa.
Coarse crackles are evident on inspiration and at times expiration. Stridor is a continuous crowing sound
of constant pitch from partial obstruction of larynx or trachea. Vesicular sounds are relatively soft, lowpitched, gentle, rustling sounds. They are heard over all lung areas except the major bronchi.
Bronchovesicular sounds are normal sounds heard anteriorly over the mainstem bronchi on either side of
the sternum and posteriorly between the scapulae with a medium pitch and intensity.
After assisting at the bedside with a thoracentesis, the nurse should continue to assess the
patient for signs and symptoms of what?
Correct Answer:
Pneumothorax
Rationale:
Because thoracentesis involves the introduction of a catheter into the pleural space, there is a risk of
pneumothorax. Thoracentesis does not carry a significant potential for causing bronchospasm, pulmonary
edema, or respiratory acidosis.
After swallowing, a 73-yr-old patient is coughing and has a wet voice. What changes of aging
could be contributing to this abnormal finding?
Correct Answer:
Decreased respiratory defense mechanisms
Rationale:
Aspiration occurs more easily in the older patient related to decreased respiratory defense mechanisms
(e.g., decreases in immunity, ciliary function, cough force, sensation in pharynx). Changes of aging
include a decreased response to hypercapnia, decreased number of functional alveoli, and increased
calcification of costal cartilage, but these do not increase the risk of aspiration
A patient has metabolic acidosis secondary to type 1 diabetes. What physiologic response should
the nurse expect to assess in the patient?
Correct Answer:
Increased respiratory rate
Rationale:
When a patient with type 1 diabetes has hyperglycemia and ketonemia causing metabolic acidosis, the
physiologic response is to increase the respiratory rate and tidal volume to blow off the excess CO 2.
Vomiting and increased urination may occur with hyperglycemia, but not as physiologic responses to
metabolic acidosis. The heart rate will increase.
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A patient with recurrent shortness of breath has just had a bronchoscopy. What is
a priority nursing action immediately after the procedure?
Correct Answer:
Monitor the patient for laryngeal edema.
Rationale:
Priorities for assessment are the patient’s airway and breathing, both of which may be compromised after
bronchoscopy by laryngeal edema. These assessment parameters supersede the importance of loss of
consciousness (LOC), pain, heart rate, and blood pressure, although the nurse should also be assessing
these.
What should the nurse inspect when assessing a patient with shortness of breath for evidence of
long-standing hypoxemia?
Correct Answer:
Fingernails
Rationale:
Clubbing, a sign of long-standing hypoxemia, is evidenced by an increase in the angle between the base
of the nail and fingernail to 180 degrees or more, usually accompanied by an increase in the depth, bulk,
and sponginess of the end of the finger.
The patient’s arterial blood gas results show the PaO2 at 65 mmHg and SaO2 at 80%. What other
manifestations should the nurse expect to observe in this patient?
Correct Answer:
Restlessness, tachypnea, tachycardia, and diaphoresis
Rationale:
With inadequate oxygenation, early manifestations include restlessness, tachypnea, tachycardia, and
diaphoresis, decreased urinary output, and unexplained fatigue. Unexplained confusion, dyspnea at rest,
hypotension, and diaphoresis; combativeness, retractions with breathing, cyanosis, and decreased
urinary output; coma, accessory muscle use, cool and clammy skin, and unexplained fatigue are later
manifestations of inadequate oxygenation.
The nurse is performing a focused respiratory assessment of a patient who is in severe
respiratory distress 2 days after abdominal surgery. What is most important for the nurse to
assess?
Correct Answer:
Auscultation of bilateral breath sounds
Rationale:
Important assessments obtained during a focused respiratory assessment include auscultation of lung
(breath) sounds. Assessment of tactile fremitus has limited value in acute respiratory distress. It is not
necessary to assess for both anterior and posterior chest expansion. Percussion of the chest wall is not
essential in a focused respiratory assessment.
When assessing a patient’s sleep-rest pattern related to respiratory health, what should the nurse
ask the patient? (Select all that apply.)
Correct Answer:
Is it hard for you to fall asleep?
Do you awaken abruptly during the night?
Do you need to sleep with the head elevated?
Rationale:
A patient with obstructive sleep apnea may have insomnia, abrupt awakenings, or both. Patients with
cardiovascular disease (e.g., heart failure that may affect respiratory health) may need to sleep with the
head elevated on several pillows (orthopnea). Sleeping more than 8 hours per night or needing to urinate
during the night is not indicative of impaired respiratory health.
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When auscultating the patient’s lower lungs, the nurse hears low-pitched sounds similar to
blowing through a straw under water on inspiration. How should the nurse document these
sounds?
Correct Answer:
Coarse crackles
Rationale:
Coarse crackles are a series of long-duration, discontinuous, low-pitched sounds caused by air passing
through an airway intermittently occluded by mucus, an unstable bronchial wall, or a fold of mucosa.
Coarse crackles are evident on inspiration and at times expiration. Stridor is a continuous crowing sound
of constant pitch from partial obstruction of larynx or trachea. Vesicular sounds are relatively soft, lowpitched, gentle, rustling sounds. They are heard over all lung areas except the major bronchi.
Bronchovesicular sounds are normal sounds heard anteriorly over the mainstem bronchi on either side of
the sternum and posteriorly between the scapulae with a medium pitch and intensity.
When assessing the patient in acute respiratory distress, what should the nurse expect to
observe? (Select all that apply.)
Correct Answer:
Cyanosis
Accessory muscle use
Rationale:
Tripod position and accessory muscle use indicate moderate to severe respiratory distress. Cyanosis may
be related to anemia, decreased oxygen transfer in the lungs, or decreased cardiac output. Therefore, it is
a nonspecific and unreliable indicator of only respiratory distress. Kussmaul respirations occur when the
patient is in metabolic acidosis to increase CO2 excretion. Increased AP diameter occurs with lung
hyperinflation from chronic obstructive pulmonary disease, cystic fibrosis, or with advanced age.
A frail older adult patient develops sudden shortness of breath while sitting in a chair. What
location on the chest should the nurse begin auscultation of the lung fields?
Correct Answer:
Bases of the posterior chest area
Rationale:
Baseline data with the most information is best obtained by auscultation of the posterior chest, especially
in female patients because of breast tissue interfering with the assessment or if the patient may tire easily
(e.g., shortness of breath, dyspnea, weakness, fatigue). Usually auscultation proceeds from the lung
apices to the bases unless it is possible the patient will tire easily. In this case, the nurse should start at
the bases.
A patient is hospitalized with pneumonia. Which diagnostic test should be used to measure the
efficiency of gas exchange in the lung and tissue oxygenation?
Correct Answer:
Arterial blood gases
Rationale:
Arterial blood gases are used to assess the efficiency of gas exchange in the lung and tissue oxygenation
as is pulse oximetry. Thoracentesis is used to obtain specimens for diagnostic evaluation, remove pleural
fluid, or instill medication into the pleural space. Bronchoscopy is used for diagnostic purposes, to obtain
biopsy specimens, and to assess changes resulting from treatment. Pulmonary function tests measure
lung volumes and airflow to diagnose pulmonary disease, monitor disease progression, evaluate
disability, and evaluate response to bronchodilators
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The nurse is caring for a patient with chronic obstructive pulmonary disorder (COPD) and
pneumonia who has an order for arterial blood gases to be drawn. What is the minimum length of
time the nurse should plan to hold pressure on the puncture site?
Correct Answer:
5 minutes
Rationale:
After obtaining blood for an arterial blood gas measurement, the nurse should hold pressure on the
puncture site for 5 minutes by the clock to be sure that bleeding has stopped. An artery is an elastic
vessel under much higher pressure than veins, and significant blood loss or hematoma formation could
occur if the time is insufficient.
A patient with a recent history of a dry cough has had a chest x-ray that revealed the presence of
nodules. In an effort to determine whether the nodules are malignant or benign, what is the
primary care provider likely to order?
Correct Answer:
Positron emission tomography (PET)
Rationale:
PET is used to distinguish benign and malignant pulmonary nodules. Because malignant lung cells have
an increased uptake of glucose, the PET scan (which uses an IV radioactive glucose preparation) can
demonstrate increased uptake of glucose in malignant lung cells. This differentiation cannot be made
using CT, a pulmonary angiogram, or thoracentesis.
The nurse is caring for a patient who had abdominal surgery yesterday. Today the patient’s lung
sounds in the lower lobes are diminished. The nurse knows this could be related to the
occurrence of:
Correct Answer:
atelectasis.
Rationale:
After surgery, there is an increased risk for atelectasis from anesthesia as well as restricted breathing
from pain. Without deep breathing to stretch the alveoli, surfactant secretion to hold the alveoli open is not
promoted. Pneumonia will occur later after surgery. Pleural effusion occurs because of blockage of
lymphatic drainage or an imbalance between intravascular and oncotic fluid pressures, which is not
expected in this case.
After assisting at the bedside with a thoracentesis, the nurse should continue to assess the
patient for signs and symptoms of what?
Correct Answer:
Pneumothorax
Rationale:
Because thoracentesis involves the introduction of a catheter into the pleural space, there is a risk of
pneumothorax. Thoracentesis does not carry a significant potential for causing bronchospasm, pulmonary
edema, or respiratory acidosis.
A patient had a right total knee replacement 2 days ago. Upon auscultation of the patient’s
posterior chest, the nurse detects discontinuous, high-pitched breath sounds just before the end
of inspiration in the lower portion of both lungs. Which statement most appropriately reflects how
the nurse should document the breath sounds?
Correct Answer:
“Fine crackles posterior right and left lower lung fields.”
Rationale:
Fine crackles are described as a series of short-duration, discontinuous, high-pitched sounds heard just
before the end of inspiration.
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The nurse is interpreting a tuberculin skin test (TST) for a patient with end-stage renal disease due
to diabetes. Which finding would indicate a positive reaction?
Correct Answer:
11-mm area of induration at the TST injection site
Rationale:
An area of induration 10 mm or larger would be a positive reaction in a person with end-stage renal
disease. Reddened, flat areas do not indicate a positive reaction. A wheal appears when the TST is
administered that indicates correct administration of the intradermal antigen. Presence of acid-fast bacilli
in the sputum indicates active tuberculosis.
The patient is calling the clinic with a cough. What assessment should be made first before the
nurse advises the patient?
Correct Answer:
Cough sound, sputum production, pattern
Rationale:
The sound of the cough, sputum production and description, and the pattern of the cough’s occurrence
(including acute or chronic) and what its occurrence is related to are the first assessments to be made to
determine the severity. Frequency of the cough will not provide a lot of information. Family history can
help to determine a genetic cause of the cough. Hematemesis is vomiting blood and not as important as
hemoptysis. Smoking is an important risk factor for chronic obstructive pulmonary disease, and lung
cancer and may cause a cough. Medications may or may not contribute to a cough as does residence
location. Weight loss, activity intolerance, and orthopnea may be related to respiratory or cardiac
problems but are not as important when dealing with a cough.
The patient with Parkinson’s disease has a pulse oximetry reading of 72% but has no other signs
of decreased oxygenation. What is the most likely explanation for the low SpO2 level?
Correct Answer:
Artifact
Rationale:
Motion is the most likely cause of the low SpO2 for this patient with Parkinson’s disease. Anemia, dark
skin color, and thick acrylic nails as well as low perfusion, bright fluorescent lights, and intravascular dyes
may also cause an inaccurate pulse oximetry result. There is no mention of these or reason to suspect
these in this question.
The nurse is palpating the patient’s chest during a focused respiratory assessment in the
emergency department. Which finding is a medical emergency?
Correct Answer:
Tracheal deviation to the left
Rationale:
Tracheal deviation is a medical emergency when it is caused by a tension pneumothorax. Tactile fremitus
increases with pneumonia or pulmonary edema and decreases in pleural effusion or lung hyperinflation.
Diminished chest movement occurs with barrel chest, restrictive disease, and neuromuscular disease.
Which patient has early clinical manifestations of hypoxemia?
Correct Answer:
A 72-yr-old patient who has four new premature ventricular contractions per minute.
Rationale:
Early clinical manifestations of hypoxemia include dysrhythmias (e.g., premature ventricular contractions),
unexplained decreased level of consciousness (e.g., disorientation), dyspnea on exertion, and
unexplained decreased urine output.
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