Ch. 16 PrepU Practice Questions

A client presents to the health care facility with a 2-week history of persistent dry, hacky cough, chest tightness, and shortness of breath with activity. The client admits to a 1-pack-per-day history of cigarette smoking for 20 years. The nurse observes a respiratory rate of 16 breaths per minute, easy and regular. Which nursing diagnosis should the nurse confirm based on this assessment data?

a) Disturbed Sleep Pattern
b) Impaired Gas Exchange
c) Ineffective Airway Clearance
d) Risk for Imbalanced Nutrition

Impaired Gas Exchange

Explanation:
Impaired Gas Exchange related to chronic lung tissue damage secondary to chronic smoking can be confirmed because of the major criteria of long-standing smoking, shortness of breath, and activity intolerance. The client’s cough is dry and hacky, which does not meet the criteria for Ineffective Airway Clearance. There is no data to support the client experiencing a disturbance in sleep or problems with nutrition.

A nurse observes a client sitting in the tripod position. What is an appropriate action by the nurse in response to this observation?

a) Observe for the use of accessory muscles
b) Auscultate for the presence of crackles
c) Palpate for tactile fremitus
d) Percuss to determine diaphragmatic excursion

Observe for the use of accessory muscles

Explanation:
The tripod position is often assumed by the client with chronic obstructive pulmonary disease (COPD) in order to help elevate the diaphragm during inspiration. This is often accompanied by the use of accessory muscles of the neck. Crackles are present in pneumonia or fluid in the lungs. Tactile fremitus helps to assess for the presence of a consolidation such as pleural effusion or pneumonia. Diaphragmatic excursion assesses the movement of the diaphragm.

The client tells the nurse that he has been coughing up pink, frothy sputum. The nurse notifies the health care provider because the client may have what condition?

a) Pulmonary edema
b) Infection
c) Atelectasis
d) Tuberculosis

Pulmonary edema

Explanation:
Pink, frothy sputum may indicate pulmonary edema. Tuberculosis sputum may be a rusty color and green sputum may indicate an infection. The client with atelectasis may not be coughing any sputum up

The nurse is preparing to perform a focused respiratory assessment on a client. The nurse should be cognizant of what anatomical characteristic of the lungs?

a) The right lung is approximately one-third larger than the left lung.
b) The right lung has three lobes, while the left lung has two lobes.
c) The lower lobes of both lungs are primarily located toward the anterior chest wall.
d) The lungs are structurally symmetrical but functionally differently.

The right lung has three lobes, while the left lung has two lobes.

Explanation:
The right lung is made up of three lobes, whereas the left lung contains only two lobes. The sizes of the lungs are not identical but do not differ by one-third. The lower lobes of both lungs are primarily located toward the posterior surface of the chest wall.

Which of the following occurs in respiratory distress?

a) Client torso leans posteriorly.
b) Skin between the ribs moves inward with inspiration.
c) The client speaks in sentences of 10-20 words.
d) Neck muscles are relaxed.

Skin between the ribs moves inward with inspiration.

Explanation:
This description is consistent with retractions, which occur with respiratory distress. Other features include speaking in short sentences, use of accessory muscles, leaning forward to gain mechanical advantage for the diaphragm, and pursed lip breathing in which the client exhales against the lips, which are pressed together.

An adult client visits the clinic and tells the nurse that he has been “spitting up rust-colored sputum.” The nurse should refer the client to the physician for possible

a) pulmonary edema.
b) asthma.
c) tuberculosis.
d) bronchitis.

tuberculosis.

Explanation:
Rust-colored sputum is associated with tuberculosis or pneumococcal pneumonia.

The nurse is reviewing the client’s health history and notes he has pectus excavatum. The nurse would assess the client for what?

a) Pectoriloquy
b) Pigeon chest
c) Funnel chest
d) Intercostal bulging

Funnel chest

Explanation:
Pectus excavatum or funnel chest occurs when the sternum and adjacent cartilages are significantly sunken inward or dented. Pigeon chest or pectus carinatum occurs when the sternum protrudes backward. Intercostal bulging is noted with trapped air. Whispering pectoriloquy is identfied when sounds are louder and clearer than the wispered sounds.

Which type of breath sounds should a nurse anticipate on auscultation of the right lower lobe in a client with right lower lobe pneumonia?

a) Diminished
b) Vesicular
c) Bronchial
d) Bronchovesicular

Bronchial

Explanation:
Bronchial sounds are normally heard over the main bronchi. The consolidation of the lung due to right lower lobe pneumonia may carry the bronchial sounds to the peripheral lung area. Vesicular sounds are heard from the bronchioles and lobes. Bronchovesicular lung sounds are normally heard over the main bronchi. Diminished breath sounds occur if the pneumonia has caused severe damage to the lung tissue.

When crackles, wheezes, or rhonchi clear with a cough, which of the following is a likely etiology?

a) Cystic fibrosis
b) Heart failure
c) Simple asthma
d) Bronchitis

Bronchitis

Explanation:
Adventitious sounds that clear with cough are usually consistent with bronchitis or atelectasis. The other conditions would not have findings that cleared with a cough.

A nurse auscultates a client’s lungs and hears fine crackles. What is an appropriate action by the nurse?

a) Instruct the client to cough forcefully
b) Assess for the use of accessory muscles
c) Listen again with the bell of the stethoscope
d) Have the client breathe through the mouth

Instruct the client to cough forcefully

Explanation:
When auscultating crackles in the lung fields, the nurse should instruct the client to cough forcefully in an effort to open the airways. Then the nurse should auscultate again and note any changes. Lung sounds should be listened to with the diaphragm because they are high pitched sounds. The bell is used for low pitched sounds such as abnormal heart sounds. Breathing through the mouth lets the air in quicker but will not clear the airways. Use of accessory muscles is seen with respiratory distress

A client has sustained a brain stem injury and is being treated in the intensive care unit. Which of the following would the nurse need to consider when assessing this client’s respiratory status?

a) The client will have a loss of involuntary respiratory control.
b) The client will have greatly increased respiratory effort.
c) The client will respond negatively to increased stimuli.
d) The client will exhibit Cheyne-Stokes respirations.

The client will have a loss of involuntary respiratory control.

Explanation:
The brain stem contains the medulla and the pons, which control involuntary respiratory effort. The negative response to stimuli is unrelated to the client’s respiratory function. Cheyne-Stokes respirations are an abnormal pattern of rhythmic breathing. The client’s breathing will not be characterized by increased effort.

Dyspnea, an uncomfortable awareness of breathing that is inappropriate to the level of exertion, is what?

a) Air hunger
b) Prolonged inspiration
c) Painful breathing
d) Audible breathing

Air hunger

Explanation:
Dyspnea is air hunger, a nonpainful but uncomfortable awareness of breathing that is inappropriate to the level of exertion, commonly termed shortness of breath.

The staff educator from the hospital’s respiratory unit is providing a public educational event. The educator is talking about health promotion activities for people with respiratory diseases or those who are at high risk for respiratory complications. What would the educator include in the presentation?

a) Encouraging adequate rest
b) Teaching strategies to reduce complications of existing diagnoses
c) Reinforcing the need for a high-calorie diet
d) Showing participants how to diagnose respiratory problems

Teaching strategies to reduce complications of existing diagnoses

Explanation:
Health promotion activities focus on preventing disease from developing (primary prevention), screening to identify conditions at an early curable stage (secondary prevention), and reducing complications of existing or established medical diagnoses (tertiary prevention)

A nurse is interviewing a client who complains of dyspnea of sudden onset. Based on this finding, the nurse should suspect which of the following causes?

a) Emphysema
b) Lung cancer
c) Sleep apnea
d) Bacterial infection

Bacterial infection

Explanation:
Gradual onset of dyspnea is usually indicative of lung changes such as emphysema, whereas sudden onset is associated with viral or bacterial infections. Lung cancer and sleep apnea are chronic conditions, which would be more likely to result in a gradual onset of dyspnea

Which subjective finding in a client with tuberculosis should a nurse recognize as an indication of the onset of pleurisy?

a) Throbbing pain that worsens on exhalation
b) Knife-like pain that worsens on inspiration
c) Dyspnea that is exaggerated by activity
d) Dyspnea that is exaggerated by lying down

Knife-like pain that worsens on inspiration

Explanation:
Knife-like pain that worsens on inspiration is a characteristic finding that indicates pleurisy in the client. Pleurisy or a pleural rub is caused when the inflamed pleural surface comes in contact with each other on inspiration. Dyspnea is exaggerated by activity but is not a characteristic feature. Clients with pleurisy do not have throbbing pain. Dyspnea in pleurisy is not exaggerated by lying down.

A person with a barrel chest has a problem doing what?

a) Coughing
b) Taking a deep breath
c) Breathing at a normal respiratory rate
d) Expelling excess oxygen

Taking a deep breath

Explanation:
Auscultation of all lung fields may not be possible because deep breathing generally worsens the level of fatigue in patients with pulmonary disorders.

A patient has a nursing diagnosis of ineffective airway clearance. What intervention would be most appropriate?Correct
Explana

a) Administer nebulized bronchodilators.
b) Increase protein intake.
c) Administer oxygen by simple face mask.
d) Teach deep breathing and coughing.

Teach deep breathing and coughing.

Explanation:
For the nursing diagnosis of Ineffective airway clearance the intervention cough and deep breathe is the most appropriate.

he nurse assesses shallow respirations of 28 breaths/minute in a client with pleurisy. The nurse interprets this finding as indicating which of the following?

a) The pattern is expected with this condition
b) Client is hypoventilating
c) These are normal Kussmaul’s respirations
d) Client may have overdosed on narcotics

The pattern is expected with this condition

Explanation:
Pleurisy creates difficulty in getting enough oxygen, and the body responds by increasing the respiratory effort (tachypnea) in an attempt to compensate. Hypoventilation or Cheyne-Stokes respiration would be noted with narcotic overdose. Kussmaul’s respirations are associated with diabetic ketoacidosis.

The clavicles extend from the acromion of the scapula to the part of the sternum termed the

a) manubrium.
b) xiphoid process.
c) body.
d) angle.

manubrium.

Explanation:
The clavicles extend from the manubrium to the acromion of the scapula.

What replaces resonance when fluid or solid tissue replaces air-containing lung or occupies the pleural space?

a) Chief complaint
b) Hyperresonance
c) Dullness
d) Tympany

Dullness

Explanation:
Dullness replaces resonance when fluid or solid tissue replaces air-containing lung or occupies the pleural space.

The nurse is caring for a client who is 48 hours postop from the repair of a fractured hip. She has a sudden onset of dyspnea without pain. What disease process would the nurse suspect?

a) Left ventricular failure
b) Chronic lung disease
c) Asthma
d) Pulmonary embolism

Pulmonary embolism

Explanation:
Risk factors for pulmonary embolism include postpartum or postoperative periods, prolonged bed rest, congestive heart failure, chronic lung disease, fractures of hip or leg, and deep venous thrombosis (often not clinically apparent).

The nurse assesses an adult client and observes that the client’s breathing pattern is very labored and noisy, with occasional coughing. The nurse should refer the client to a physician for possible

a) congestive heart failure.
b) renal failure.
c) chronic bronchitis.
d) atelectasis.

chronic bronchitis.

Explanation:
Labored and noisy breathing is often seen with severe asthma or chronic bronchitis.

When assessing whispered pectoriloquy, the nurse would instruct a client to do which of the following?

a) Say “ninety-nine.”
b) Cough each time the stethoscope is moved.
c) Say the letter “e.”
d) Softly repeat the words “one-two-three.”

Softly repeat the words “one-two-three.”

Explanation:
Softly whispering “one-two-three” while the nurse auscultates the chest is a correct instruction for the whispered pectoriloquy test. Having the client say “ninety-nine” is used to test bronchophony. Saying the letter “e” is used to test egophony. Having the client cough is useful if an abnormal sound is heard during auscultation to determine if coughing clears the lungs.

he nurse assesses chest expansion in a 30-year-old man and finds it to be 8 cm. The nurse should document this as which of the following?

a) Hypoexpansion
b) Normal expansion
c) Limited expansion
d) Hyperexpansion

Normal expansion

Explanation:
Normal chest expansion ranges from 5 to 10 cm symmetrically. A finding of 8 cm would be well within the normal parameters.

The nurse percusses the lungs of a patient with pneumonia. What percussion note would the nurse expect to document?

a) hyperresonance
b) flatness
c) dullness
d) tympany

dullness

The nurse assesses an adult client’s thoracic area and observes a markedly sunken sternum and adjacent cartilages. The nurse should document the client’s

a) pectus thorax.
b) pectus carinatum.
c) pectus diaphragm.
d) pectus excavatum.

pectus excavatum.

Explanation:
Pectus excavatum is a markedly sunken sternum and adjacent cartilages (often referred to as funnel chest). It is a congenital malformation that seldom causes symptoms other than self-consciousness.

A new nurse on the telemetry unit is reviewing information about how to correctly read electrocardiograms. The nurse is expected to know that the PR interval represents what event?

a) The spread of depolarization and sodium release in the ventricles to cause ventricular contraction
b) Relaxation of the ventricles and repolarization of the cells
c) The spread of depolarization in the atria
d) The time from firing of the sinoatrial (SA)node to the beginning of depolarization in the ventricle

the time from firing of the sinoatrial (SA)node to the beginning of depolarization in the ventricle

Explanation:
PR interval represents the time from the firing of the SA node to the beginning of ventricular depolarization (includes a slight pause at the AV junction).

In palpating the chest of a client, a nurse feels a U-shaped indentation on the superior border of the manubrium. The nurse recognizes this landmark as which of the following?

a) Xiphoid process
b) Suprasternal notch
c) Acromion of the scapula
d) Sternal angle

Suprasternal notch

Explanation:
The sternum, or breastbone, lies in the center of the chest anteriorly and is divided into three parts: the manubrium, the body, and the xiphoid process. The manubrium connects laterally with the clavicles (collar bones) and the first two pairs of ribs. The clavicles extend from the manubrium to the acromion of the scapula. A U-shaped indentation located on the superior border of the manubrium is an important landmark known as the suprasternal notch. A few centimeters below the suprasternal notch, a bony ridge can be palpated at the point where the manubrium articulates with the body of the sternum. This landmark, often referred to as the sternal angle (or angle of Louis), is also the location of the second pair of ribs and becomes a reference point for counting ribs and intercostal spaces

The nurse is assessing a client’s respiratory rate and rhythm during the beginning of a shift. The nurse knows that a normal breathing rate is between approximately 10 and 20 breaths per minute, but the client’s rate is 29 breaths per minute. How should the nurse respond to this assessment finding?

a) Ask the client if she has smoked recently.
b) Report the finding to the client’s primary care provider.
c) Palpate the client’s anterior and posterior thorax.
d) Ask the client if she has recently exerted herself.

Ask the client if she has recently exerted herself.

Explanation:
Respiratory rate is highly dependent on recent exertion and activity. This variable should be ruled out before making a referral. Palpation is unlikely to ascertain the cause of the increased respiratory rate. Smoking is a possible cause, but activity is more likely

A 47-year-old receptionist comes to the office with fever, shortness of breath, and a productive cough with golden sputum. She says she had a cold last week and her symptoms have only worsened despite using over-the-counter cold remedies. She denies any weight gain, weight loss, or cardiac or gastrointestinal symptoms. Her past medical history includes type 2 diabetes for 5 years and high cholesterol level. She takes an oral medication for both diseases. She has had no surgeries. She denies tobacco, alcohol, or drug use. Her mother has diabetes and high blood pressure. Her father passed away from colon cancer. Examination reveals a middle-aged woman appearing her stated age. She looks ill and her temperature is elevated at 101 degrees Farenheit. Her blood pressure and pulse are unremarkable. Her head, eyes, ears, nose, and throat examination are unremarkable except for edema of the nasal turbinates. On auscultation she has decreased air movement and coarse crackles are heard over the left lower lobe. There is dullness on percussion, increased fremitus during palpation, and egophony and whispered pectoriloquy on auscultation. What disorder of the thorax or lung best describes her symptoms?

a) Spontaneous pneumothorax
b) Pneumonia
c) Asthma
d) Chronic obstructive pulmonary disease (COPD)

Pneumonia

Explanation:
Pneumonia is usually associated with dyspnea, cough, and fever. On auscultation there can be coarse or fine crackles heard over the affected lobe. Percussion over the affected area is dull, and there is often an increase in fremitus. Egophony and pectoriloquy are heard because of increased sound transmission of high-pitched components of sounds. The multiple air-filled chambers of the alveoli usually filter out these higher frequencies.

While examining a client, the nurse observes the client’s chest to be barrel shaped. The nurse would interpret this as indicating which of the following?

a) Emphysema
b) Pneumonia
c) Funnel chest
d) Pectus excavatum

Emphysema

Explanation:
A barrel chest is often seen in emphysema because of hyperinflation of the lungs. A change in chest shape would be rare with pneumonia. Pectus excavatum or funnel chest is a congenital malformation. (

Which of the following conditions would produce a hyperresonant percussion note?

a) Empyema
b) Large pneumothorax
c) Pleural effusion
d) Lobar pneumonia

Large pneumothorax

Explanation:
There is a great deal of free air in the chest with a large pneumothorax, which produces a hyperresonant note. The other three conditions produce dullness by dampening the percussion note with fluid.

A high-pitched crowing sound from the upper airway results from tracheal or laryngeal spasm and is called what?

a) Crackles
b) Rales
c) Stridor
d) Wheezes

Stridor

Explanation:
Stridor, a high-pitched crowing sound from the upper airway, results from tracheal or laryngeal spasm. In severe laryngospasm, the larynx may completely close off. This life-threatening emergency requires immediate medical assistance. Crackles, wheezes, and rales are adventitious breath sounds heard upon auscultation of the lungs.

A client presents to the health care clinic and reports a recent onset of a persistent cough. The client denies any shortness of breath, change in activity level, or other findings of an acute upper respiratory tract illness. What question by the nurse is most appropriate to further assess the cause for the cough?

a) “Have you changed your diet within the past few weeks?”
b) “How much do you exercise during the week?”
c) “Do you feel that you are under a great deal of stress?’
d) “Are you taking any medications on a regular basis?”

“Are you taking any medications on a regular basis?”

Explanation:
A persistent cough without any other respiratory symptoms could be related to new medications, especially beta blockers or angiotensin converting enzyme (ACE) inhibitors, which are prescribed for hypertension. A change in diet and exercise are healthy behaviors that would not cause a persistent cough. Stress often causes shortness of breath

The nurse is assessing the apices of the client’s lungs. The nurse should locate them at which position?

a) At the level of the diaphragm
b) At about the tenth rib
c) Slightly above the clavicle
d) Near the level of the eighth rib

Slightly above the clavicle

Explanation:
The apex of each lung extends slightly above the clavicle. The base is at the level of the diaphragm. Laterally, lung tissue reaches the level of the eighth rib and posteriorly, the base lies at about the tenth rib.

A grandmother brings her 13-year-old grandson for evaluation. She noticed last week when he took off his shirt that his breastbone seemed collapsed. He seems embarrassed and says that it has been that way for awhile. He states he has no symptoms from it and that he just tries not to take off his shirt in front of anyone. He denies any shortness of breath, chest pain, or lightheadedness on exertion. His past medical history is unremarkable. He is in sixth grade and just moved in with his grandmother after his father was transferred for a work contract. His mother died several years ago in a car accident. He states that he does not smoke and has never touched alcohol. Examination shows a teenage boy appearing his stated age. Visual examination of his chest reveals that the lower portion of the sternum is depressed. Auscultation of the lungs and heart is unremarkable. What disorder of the thorax best describes these findings?

a) Barrel chest
b) Thoracic kyphoscoliosis
c) Funnel chest (pectus excavatum)
d) Pigeon chest (pectus carinatum)

Instruct the client to cough forcefully

Explanation:
When auscultating crackles in the lung fields, the nurse should instruct the client to cough forcefully in an effort to open the airways. Then the nurse should auscultate again and note any changes. Lung sounds should be listened to with the diaphragm because they are high-pitched sounds. The bell is used for low-pitched sounds such as abnormal heart sounds. Breathing through the mouth lets the air in quicker but will not clear the airways. Use of accessory muscles is seen with respiratory distress

Adventitious sounds related to atelectasis and pulmonary edema are first evident when auscultating what area of the respiratory system?

a) Bases
b) Bronchi
c) Trachea
d) Apices

Bases

Explanation:
Careful auscultation of the bases is important because they are often the first area to collapse with atelectasis when a patient is immobile. This is also where fluid collects in a pleural effusion (outside the lungs) or with pulmonary edema (in the lungs) in heart failure.

A client comes to the clinic and states, “I have a bad cold and am having trouble breathing.” The nurse checks the client’s breath sounds and hears bilateral fine crackles at the base. Of what is this finding indicative?

a) Fluid in the bronchus
b) No fluid present
c) Fluid in the bronchioles
d) Fluid in the alveoli

Fluid in the alveoli

Explanation:
When fluid fills the alveoli, fine crackles may be audible on auscultation. Excessive fluid in the alveoli may lead to airway collapse and decreased breath sounds. Fine crackles are not indicative of fluid in the bronchioles or bronchus or the absence of fluid in the lungs

A grandmother brings her 13-year-old grandson for evaluation. She noticed last week when he took off his shirt that his breastbone seemed collapsed. He seems embarrassed and says that it has been that way for awhile. He states he has no symptoms from it and that he just tries not to take off his shirt in front of anyone. He denies any shortness of breath, chest pain, or lightheadedness on exertion. His past medical history is unremarkable. He is in sixth grade and just moved in with his grandmother after his father was transferred for a work contract. His mother died several years ago in a car accident. He states that he does not smoke and has never touched alcohol. Examination shows a teenage boy appearing his stated age. Visual examination of his chest reveals that the lower portion of the sternum is depressed. Auscultation of the lungs and heart is unremarkable. What disorder of the thorax best describes these findings?

a) Funnel chest (pectus excavatum)
b) Thoracic kyphoscoliosis
c) Barrel chest
d) Pigeon chest (pectus carinatum)

Funnel chest (pectus excavatum)

Explanation:
Funnel chest is caused by a depression in the lower portion of the sternum. If severe enough there can be compression of the heart and great vessels, leading to murmurs on auscultation. This is usually only a cosmetic problem, but corrective surgeries can be performed if necessary.

A nurse is palpating the sternum of a client. If the client is healthy, which of the following would characterize his costal angle?

a) <90 degrees b) >110 degrees
c) 100-110 degrees
d) 90-100 degrees

<90 degrees Explanation: The right and left costal margins meeting at the level of the xiphoid process form an angle between them. This angle, commonly referred to as the costal angle, is an important landmark for assessment. It is normally less than 90 degrees but may be increased in instances of long-standing hyperinflation of the lungs, as in emphysema.

A nurse in the operating room has a client who just underwent gastric bypass surgery and weighs 243 kilograms (534.6 pounds). Upon extubation, the client’s oxygen saturation drops to 84% and the client has difficulty catching her breath. What could be causing these problems?

a) Pain, which is inhibiting the client’s ability to breathe
b) Anesthesia, which is causing the client to be more sleepy than usual
c) Obesity, which can limit chest wall expansion and compromise breathing
d) A progressive loss of muscle function

Obesity, which can limit chest wall expansion and compromise breathing

Explanation:
Extreme obesity can limit chest wall expansion (and thus compromise breathing). Progressive loss of muscle function is related to diseases such as muscular dystrophy, not obesity. Pain and anesthesia would not be causes of decreased oxygen saturation and breathing difficulty.

A nurse performs a respiratory assessment on a client and notes the respiratory rate to be 10 breaths per minute. The nurse knows the proper term for this rate is what?

a) Hypoventilation
b) Hyperventilation
c) Tachypnea
d) Bradypnea

Bradypnea

Explanation:
A respiratory rate less than 10 breaths per minute is called bradypnea. Tachypnea is a respiratory rate greater than 24 breaths per minute. Hyperventilation is used to describe respirations that are increased in rate and depth. Hypoventilation is a rate that is decreased with a decrease in depth, and with an irregular pattern.

A client presents to the health care facility with sudden onset of shortness of breath, inability to lie flat, and a deep, wet cough. A nurse observes a respiratory rate of 18 breaths per minute, use of accessory muscles to breathe, and inability to cough up secretions. Which nursing diagnosis can be confirmed with this data?

a) Impaired Gas Exchange
b) Ineffective Airway Clearance
c) Ineffective Breathing Pattern
d) Risk for Respiratory Infection

Normal expansion

Explanation:
Normal chest

During the lung assessment for a client with pneumonia, the nurse auscultates low-pitched bubbling, moist sounds that persists from early inspiration to early expiration. How should the nurse document these sounds?

a) Sibilant wheezes
b) Sonorous wheezes
c) Pleural friction rubs
d) Coarse crackles

Ineffective Airway Clearance

Explanation:
The nurse observes the client’s inability to cough up secretions which is a major defining characteristic for accepting the nursing diagnosis of Ineffective Airway Clearance. There is no indication that this client has or is at risk for an infection. Impaired Gas Exchange can not be confirmed because there is no indication that the client is having poor muscle tone or has damage to lung tissue. For Ineffective Breathing Pattern to be confirmed the client must demonstrate a pattern of hyper or hypoventilation.

While assessing the thoracic area of an adult client, the nurse plans to auscultate for voice sounds. To assess bronchophony, the nurse should ask the client to

a) repeat the phrase “ninety-nine.”
b) repeat the letter “A.”
c) repeat the letter “E.”
d) whisper the phrase “one-two-three.”

repeat the phrase “ninety-nine.”

Explanation:
To assess bronchophony ask the client to repeat the phrase “ninety-nine” while you auscultate the chest wall.

Upon inspection of a client’s chest, a nurse observes an increase in the ratio of anteroposterior to transverse diameter. The nurse recognizes this as a finding in which disease process?

a) Tuberculosis
b) Pneumothorax
c) Chronic obstructive pulmonary disease
d) Carcinoma of the lungs

Chronic obstructive pulmonary disease

Explanation:
An increase in the ratio of anteroposterior to transverse diameter is seen in clients with chronic obstructive pulmonary disease. This occurs because of air trapped in the airways that causes hyperinflation and overdistention. Carcinoma of the lungs, pneumothorax, and tuberculosis do not change the chest diameter.

During the lung assessment for a client with pneumonia, the nurse auscultates low-pitched bubbling, moist sounds that persists from early inspiration to early expiration. How should the nurse document these sounds?

a) Sonorous wheezes
b) Coarse crackles
c) Pleural friction rubs
d) Sibilant wheezes

Coarse crackles

Explanation:
Low-pitched bubbling, moist sounds that persists from early inspiration to early expiration and sounds like softly separating Velcro should be documented as coarse crackles. These sounds are produced when inhaled air comes into contact with secretions in the large bronchi and trachea. Pleural friction rub is low-pitched, dry, grating sound which is superficial and occurs during both inspiration and expiration. Sonorous wheezes are low pitched snoring or moaning sounds that may be heard primarily during expiration but may be heard throughout the respiratory cycle. Sibilant wheezes are high-pitched musical sounds heard primarily during expiration but may also be heard on inspiration.

During a health screening event, the nurse is assessing a client’s risk factors for lung cancer. When addressing the most significant risk factor for lung cancer, the nurse should question the client about which of the following?

a) History of tobacco use
b) Childhood exposure to air pollution
c) History of recurrent lung infections
d) History of working in a factory or smelter

History of tobacco use

Explanation:
Pollution and occupational toxins are risk factors for lung cancer, but cigarette smoking is the primary risk factor. Infections do not usually precede lung cancer.

The nurse is assessing a 79-year-old client’s posterior thorax during a focused respiratory assessment. The nurse should attribute what assessment finding to age-related changes?

a) Audible wheeze
b) Asymmetrical chest expansion
c) Inaudible posterior lung sounds
d) Slight kyphosis

Slight kyphosis

Explanation:
Kyphosis (an increased curve of the thoracic spine) is common in older clients. Inaudible lung sounds, wheezing, and asymmetrical expansion are considered pathologic findings in clients of all ages

A client has a history of emphysema. During the respiratory assessment, the nurse percusses the client’s chest, expecting to find which of the following?

a) Tympany
b) Hyperresonance
c) Resonance
d) Dullness

Hyperresonance

Explanation:
Hyperresonance would be noted in a client with emphysema due to air trapping. Dullness is noted with fluid or solid tissue replacing air in the lung. Resonance is the normal finding on lung percussion. Tympany would be noted over areas of air, such as a gastric bubble in the stomach

A client is diagnosed with pulmonary edema, and the nurse is performing a rapid assessment prior to treatment. The nurse would be most concerned about which of the following assessment findings related to the client’s sputum?

a) Pink and frothy
b) Rust-tinged
c) Yellowish and foul-smelling
d) White or cream-colored

Pink and frothy

Explanation:
Pink sputum is associated with pulmonary edema. White sputum typically is seen with the common cold. Yellow sputum suggests a bacterial infection. Rust-colored sputum is associated with tuberculosis or pneumococcal pneumonia.

Which lung sound possesses the following characteristics? Expiration is longer than inspiration; the sound is louder and higher in pitch with a short silence between inspiration and expiration.

a) Bronchovesicular
b) Vesicular
c) Bronchial
d) Tracheal

Bronchial

Explanation:
These characteristics are consistent with bronchial breath sounds. Be alert for these because they may occur elsewhere and indicate pneumonia or other pathology. The current explanation for this phenomenon is that fluid carries the sound from the trachea very well to the chest wall. This same explanation explains “ee” to “aa” changes, whispered pectoriloquy, bronchophony, and others in which high-frequency sounds, normally blocked by air-filled alveoli, could be transmitted to the chest wall

A client is admitted to the health care facility with a diagnosis of left lower lobe pneumonia. What change in egophony should the nurse expect to find in the left lower lobe?

a) “Ninety nine” is soft and muffled
b) “1-2-3” is heard clearly
c) Letter “E” is heard distinctly
d) Sound is louder and sounds like “A”

Sound is louder and sounds like “A”

Explanation:
To perform egophony, the nurse asks the client to repeat the letter “E” while listening with the stethoscope. Over normal lung tissue, the sound will be soft and muffled but the letter should be distinguishable. In areas of consolidation, such as pneumonia, the letter “E” will sound louder and sound like the letter “A”. Bronchophony uses the words “Ninety nine”. Whispered pectoriloquy uses the phrase “1-2-3”.

A nurse asks a client to say “ninety-nine” as the nurse palpates the posterior thorax. The nurse is assessing which of the following?

a) Egophony
b) Chest expansion
c) Bronchophony
d) Fremitus

Eremites

Explanation:
Fremitus is assessed by asking a client to say “ninety-nine” as the nurse palpates the thorax. Bronchophony is assessed by asking the client to say “ninety-nine” as the nurse auscultates the chest wall. Chest expansion is assessed by measuring the distance the examiner’s thumbs move when the client takes a deep breath. Egophony is assessed by having the client repeat the letter “e” as the nurse auscultates.

When auscultating the lungs, the nurse listens over symmetrical lung fields for which of the following?

a) Two full breaths every 10 seconds through the nose
b) Two full breaths in through the mouth and out through the nose
c) One quiet full inspiration through pursed lips
d) One deep inspiration and expiration through the open mouth

One deep inspiration and expiration through the open

Explanation:
Lung auscultation is performed for one full breath over symmetrical lung fields. The client should be encouraged to breathe deeply through an open mouth.

While assessing an adult client’s lungs during the postoperative period, the nurse detects coarse crackles. The nurse should refer the client to a physician for possible

a) bronchitis.
b) pneumonia.
c) asthma.
d) pleuritis.

pneumonia.

Explanation:
Crackles occurring late in inspiration are associated with restrictive diseases such as pneumonia.

The nurse obtains a flat sound when percussing the right lower lobe of a patient. What does this assessment finding indicate to the nurse?

a) Gastric air bubble
b) Pleural effusion
c) Healthy lung tissue
d) Chronic bronchitis

Pleural effusion

Explanation:
When a flat sound is percussed over lung tissue, this is an indication of a pleural effusion. Resonance is the percussion sound of healthy lung tissue. The sound of a gastric air bubble is tympany. Resonance is the percussion sound associated with chronic bronchitis

What would the nurse expect to hear when auscultating the lungs of a client who is dehydrated?

a) Sibilant wheeze
b) Stridor
c) Decreased breath sounds
d) Friction rub

Friction rub

Explanation:
The pleural space is one of the physiologic third spaces for body fluid storage. Severe dehydration will reduce the volume of pleural fluid resulting in the increased transmission of lung sounds and a possible friction rub. Decreased breath sounds may indicate an obstruction due to little air moving in and out. Sibilant wheezes are often heard with bronchitis; stridor occurs with severe broncholaryngospams, such as croup

Adventitious sounds related to atelectasis and pulmonary edema are first evident when auscultating what area of the respiratory system?

a) Bases
b) Trachea
c) Apices
d) Bronchi

Bases

Explanation:
Careful auscultation of the bases is important because they are often the first area to collapse with atelectasis when a patient is immobile. This is also where fluid collects in a pleural effusion (outside the lungs) or with pulmonary edema (in the lungs) in heart failure

A 37-year-old man presents at the emergency department complaining that he
is having trouble breathing. What would the nurse prioritize in this patient’s acute assessment?

a) Inspecting the oral mucosa
b) Assessing pulse
c) Performing full lung function testing
d) Assessing oral temperature

Assessing pulse

Explanation:
If a patient has acute shortness of breath, immediately assess respiratory and pulse rates, blood pressure, and oxygen saturation.

The nurse assesses an adult client’s breath sounds and hears sonorous wheezes, primarily during the client’s expiration. The nurse should refer the client to a physician for possible

a) asthma.
b) chronic emphysema.
c) pleuritis.
d) bronchitis.

bronchitis.

Explanation:
Sonorous wheezes are often heard in cases of bronchitis.

A 72-year-old woman has been admitted to the hospital for treatment of bacterial pneumonia. At the beginning of shift, the nurse notes that the client’s previously existing wheeze is not as loud as it had been the day prior and is now audible only on inspiration. How should the nurse best interpret this change in the client’s condition?

a) Inspiratory wheezing suggests that the client’s basilar secretions have become consolidated.
b) The apparent decrease in the client’s wheezing signals that antibiotic therapy is effective.
c) The client is displaying a comorbidity of asthma.
d) The client’s upper airway may be partially obstructed.

The client’s upper airway may be partially obstructed.

Explanation:
Stridor indicates a partial obstruction of the larynx or trachea and necessitates immediate intervention. It is not a sign of improvement in the client’s condition, consolidation of secretions, or the presence of asthma.

When assessing posteriorly, where would the trachea bifurcate into its mainstem bronchi?

a) Sternal angle
b) Midaxillary line
c) Suprasternal notch
d) T4 spinous process

T4 spinous process

Explanation:
The trachea bifurcates into its mainstem bronchi at the levels of the sternal angle anteriorly and the T4 spinous process posteriorly.

Which characteristic feature of the sternum should the nurse observe in a client with the diagnosis of pectus carinatum?

a) Forward protrusion
b) Sunken along with the adjacent cartilages
c) Horizontal sternum with increased intercostal angle
d) Midline and straight

Forward protrusion

Explanation:
A client with pectus carinatum has a forward protrusion of the sternum causing the adjacent ribs to slope backward. Sunken sternum and adjacent cartilages are seen in funnel chest. Midline and straight position of the sternum is the normal anatomical position. Horizontal sternum with increased intercostal angle is seen in barrel chest

A nurse palpates for tactile fremitus and notes that the vibrations diminish towards the base of the lungs. What should the nurse recognize about this finding?

a) Atelectasis has occurred
b) Decreasing intensity is normal at the base
c) An area of consolidation is present
d) Client needs to speak louder

Decreasing intensity is normal at the base

Explanation:
Fremitus should be symmetrical and easily identifiable in the upper lobes. A decrease in intensity is normal when moving towards the base of the lungs. Unequal fremitus is a result of consolidation, bronchial obstruction, air trapping, pleural effusion, or pneumothorax. Speaking louder would be necessary if no vibrations were felt at any location on the thorax.

The results of a client’s ECG and D-dimer levels suggest a pulmonary embolism. Which of the following history and examination findings would the nurse expect in light of this diagnosis?

a) Sudden onset of dyspnea
b) Relief of dyspnea with guided deep breathing
c) History of heart failure
d) Fine crackles to bases on auscultation

Sudden onset of dyspnea

Explanation:
The arterial occlusion that results in pulmonary embolism normally manifests as a sudden onset of dyspnea, which deep breathing is unlikely to relieve, because part of the pulmonary arterial tree is occluded. A history of heart failure is not a notable risk factor. Absent breath sounds, not crackles, are an expected finding on auscultation

A client has a nursing diagnosis of impaired gas exchange related to alveolar-capillary membrane changes. What interventions are appropriate in this situation? Select all that apply.

a) Reduce fever
b) Administer oxygen
c) Facilitate deep breathing
d) Use an incentive spirometer
e) Increase fluids

• Administer oxygen
• Facilitate deep breathing
• Use an incentive spirometer

Explanation:
Interventions that are appropriate for a client with impaired gas exchange related to alveolar-capillary membrane changes include administering oxygen, teaching deep breathing, and encouraging use of incentive spirometery or an inhaler. Neither increasing fluids nor reducing fever is an appropriate intervention with this nursing diagnosis.

A nurse is assessing a client with acute asthma. Which adventitious breath sound should the nurse expect to hear in this client?

a) Sibilant wheezes heard primarily during expiration but may also be heard on inspiration
b) Fine crackles occurring late in inspiration
c) Sonorous wheezes heard primarily during expiration but may be heard throughout the respiratory cycle
d) Course crackles occurring from early inspiration to early expiration

Sibilant wheezes heard primarily during expiration but may also be heard on inspiration

Explanation:
Sibilant wheezes are often heard in cases of acute asthma or chronic emphysema. Fine crackles occurring late in inspiration are associated with restrictive diseases such as pneumonia and congestive heart failure. Course crackles that persist from early inspiration to early expiration may indicate pneumonia, pulmonary edema, or pulmonary fibrosis. Sonorous wheezes are often heard in cases of bronchitis or single obstructions and snoring before an episode of sleep apnea.

A 25-year-old accountant presents to the clinic with intermittent lower right-sided chest pain for several days. He describes it as knifelike and states it only lasts for 3 to 5 seconds, taking his breath away. He states he feels like he has to breathe shallowly to keep it from recurring. The only thing that makes it better is lying quietly on his right side. It is much worse when he takes a deep breath. He has taken some acetaminophen and put a heating pad on his side, but neither has helped. He remembers that 2 weeks ago he had an upper respiratory infection with a severe hacking cough. He denies any recent trauma. His past medical history is unremarkable. His parents and siblings are in good health. He has recently married with a baby due in 2 months. He denies any smoking or illegal drugs. He drinks two to three beers once a month. He states that he eats a healthy diet and runs regularly, but not since his recent illness. He denies any cardiac, gastrointestinal, or musculoskeletal symptoms. On examination he is lying on his right side but appears quite comfortable. His temperature, blood pressure, pulse, and respirations are unremarkable. His chest has normal breath sounds on auscultation. Percussion of the chest is unremarkable. During palpation the ribs are nontender.
What disorder of the chest best describes his symptoms?

a) Pericarditis
b) Angina pectoris
c) Chest wall pain
d) Pleural pain

Pleural pain

Explanation:
This pain is sharp and knifelike and occurs over the affected area of pleura. Breathing deeply usually makes the pain worse, whereas lying quietly on the affected side makes the pain better. Pleurisy often occurs from inflammation due to an infection, neoplasm, or autoimmune disease.

A nurse assesses the respiration pattern on a client who arrives in the emergency department due to an overdose of narcotics. The nurse notes that the respirations are decreased in rate and depth, and have an irregular pattern. How should the nurse document this finding?

a) Biot’s respiration
b) Cheyne-Stokes respiration
c) Bradypnea
d) Hypoventilation

Hypoventilation

Explanation:
Hypoventilation is decreased rate, decreased depth, and irregular pattern of respiration. A client with regular pattern characterized by alternating periods of deep, rapid breathing followed by periods of apnea has Cheyne-Stokes respiration. A client with irregular pattern characterized by varying depth and rate of respirations followed by periods of apnea has Biot’s respiration. A client with bradypnea may have a regular respiration rate of less than 10/min

What associated symptoms might a patient with a history of chronic bronchitis have? (Mark all that apply.)

a) Wheezing
b) Chronic productive cough
c) Orthopnea
d) Paroxysmal nocturnal dyspnea
e) Recurrent respiratory infections

• Wheezing
• Chronic productive cough
• Recurrent respiratory infections

Explanation:
Associated symptoms of chronic bronchitis include chronic productive cough and recurrent respiratory infections; wheezing may also develop.

Which finding during an assessment of a client should alert the nurse to the presence of a persistent atelectasis?

a) The presence of crepitus on palpation
b) Unequal expansion of the chest
c) A depressed sternum and cartilages
d) Retraction of intercostal spaces

Unequal expansion of the chest

Explanation:
Unequal expansion of the chest indicates atelectasis or lung collapse. The inhaled air is unable to inflate the diseased lung; therefore, there is an unequal expansion of the chest. Crepitus on palpation can be found in clients with an open thoracic injury or with a tracheostomy. Sunken sternum and adjacent cartilages are seen in funnel chest. Retraction of intercostal spaces occurs in labored breathing

When percussing the scapula of a client, which of the following would the nurse expect to hear?

a) Hyperresonance
b) Resonance
c) Flatness
d) Dullness

Flatness

Explanation:
Normally, percussion over the scapula elicits flat tones. Resonance is heard over the normal lung tissue. Dullness is heard when fluid or solid tissue replaces air in the lung. Hyperresonance is elicited in cases of trapped air such as in emphysema or pneumothorax.

While assessing the health of a client’s respiratory system, the nurse is palpating for fremitus. What instruction should the nurse provide to the client during this component of assessment?

a) “Please say the number ‘ninety-nine’ for me.”
b) “Say the letter ‘e’ and keep saying it until I tell you to stop.”
c) “When I say so, please exhale forcefully and hold the breath.”
d) “Breathe in as deeply as you can and hold your breath until I say.”

“Please say the number ‘ninety-nine’ for me.”

Explanation:
To palpate for fremitus, the nurse uses the ball or ulnar edge of one hand to assess for vibrations of air in the bronchial tubes transmitted to the chest wall. As the nurse moves a hand to each area, the client is asked to say “ninety-nine.” None of the other listed actions will allow the nurse to assess for vibration in the chest wall.

The school nurse assesses unequal shoulder and scapula height in an adolescent. Which of the following would the nurse assess next?

a) Hip levels
b) Spinal column
c) Lateral aspect of the thorax.
d) Lung volume

Spinal column

Explanation:
Unequal shoulder and scapula heights in an adolescent may represent scoliosis and may be further assessed by inspecting the spinal column for curves. Assessing the lateral aspect of the thorax or lung volumes is not indicated. Hip levels may be assessed later on to gather additional data to support possible scoliosis.

When assessing the breath sounds of a newly admitted patient, the nurse notes increased transmission of voice sounds over the right lung. What would this indicate to the nurse?

a) The lung is overinflated
b) The lung is full of fluid
c) The lung has become airless
d) The lung has an embolus

The lung has become airless

Explanation:
Increased transmission of voice sounds suggests that air-filled lung has become airless.

Adventitious sounds related to atelectasis and pulmonary edema are first evident when auscultating what area of the respiratory system?

a) Apices
b) Bases
c) Trachea
d) Bronchi

Bases

Explanation:
Careful auscultation of the bases is important because they are often the first area to collapse with atelectasis when a patient is immobile. This is also where fluid collects in a pleural effusion (outside the lungs) or with pulmonary edema (in the lungs) in heart failure

The apex of each lung is located at the

a) level of the diaphragm.
b) left oblique fissure.
c) level of the sixth rib.
d) area slightly above the clavicle.

area slightly above the clavicle.

Explanation:
The apex of each lung extends slightly above the clavicle.

What is the best guide to make vertical locations on the chest?

a) Midclavicular line
b) 5th intercostal space
c) Angle of Henri
d) Sternal angle

Sternal angle

Explanation:
To make vertical locations, you must be able to count the ribs and interspaces. The sternal angle, also termed the angle of Louis, is the best guide.

When assessing the posterior chest, what is a starting point for counting ribs and interspaces?

a) 8th rib
b) 12th rib
c) 10th rib
d) 6th rib

12th rib

Explanation:
Posteriorly, the 12th rib is another possible starting point for counting ribs and interspaces: it helps locate findings on the lower posterior chest and provides an option when the anterior approach is unsatisfactory.

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