Deck 26: Nursing Assessment: Respiratory System

Question 1

In analyzing the results of a patient's blood gas analysis, the nurse will be most concerned about an

A) arterial oxygen tension (PaO₂) of 60 mm Hg.
B) arterial oxygen saturation (SaO₂) of 91%.
C) arterial carbon dioxide (PaCO₂) of 47 mm Hg.
D) arterial bicarbonate level (HCO₃) of 27 mEq/L.

Answer 1

arterial oxygen tension (PaO₂) of 60 mm Hg.

Question 2

A patient who is restricted to bed rest asks the nurse the purpose of the deep breathing exercises. Which reply by the nurse is correct?

A) Deep breathing enhances ciliary activity and promotes bronchial clearance.
B) Deep breathing stretches the alveoli and stimulates the production of surfactant.
C) Deep breathing increases the diaphragmatic strength improving respiratory effort.
D) Deep breathing stimulates the Hering-Breuer reflex to increase respiratory rate.

Answer 2

Deep breathing stretches the alveoli and stimulates the production of surfactant.

Question 3

An 80-year-old patient breathing room air has an ABG analysis. The nurse interprets which results as normal?

A) pH 7.38, arterial carbon dioxide (PaO₂) 82 mm Hg, PaCO₂ 40 mm Hg, and O₂ sat 92%
B) pH 7.32, PaO₂ 85 mm Hg, PaCO₂ 55 mm Hg, and O₂ sat 90%
C) pH 7.48, PaO₂ 90 mm Hg, PaCO₂ 31 mm Hg, and O₂ sat 98%
D) pH 7.52, PaO₂ 91 mm Hg, PaCO₂ 42 mm Hg, and O₂ sat 94%

Answer 3

pH 7.38, arterial carbon dioxide (PaO₂) 82 mm Hg, PaCO₂ 40 mm Hg, and O₂ sat 92%

Question 4

A patient with a chronic cough with blood-tinged sputum undergoes a bronchoscopy. Following the bronchoscopy, the nurse should

A) check vital signs every 15 minutes for 2 hours.
B) place the patient on bed rest for at least 4 hours.
C) keep the patient NPO until the gag reflex returns.
D) elevate the head of the bed to 80 to 90 degrees.

Question 5

When admitting a patient who has a pleural effusion, which technique will the nurse use to assess for tactile fremitus?

A) Percuss over the entire posterior chest.
B) Use the fingertips to assess for vibration.
C) Place the palms of the hands on the chest wall.
D) Auscultate while the patient says "ninety-nine."

Question 6

When auscultating a patient's chest while the patient takes a deep breath, the nurse hears loud, high-pitched, "blowing" sounds at both lung bases. The nurse will document these as

A) adventitious sounds.
B) abnormal sounds.
C) vesicular sounds.
D) normal sounds.

Question 7

While assessing the role-relationship health pattern in a patient with respiratory problems, the nurse should specifically ask about

A) any history of cigarette smoking.
B) recent alterations in sexual activity.
C) the course of the patient's illness.
D) work exposure to respiratory irritants.

Question 8

The health care provider performs a thoracentesis on a patient with a right pleural effusion. In preparing the patient for the procedure, the nurse positions the patient

A) supine with the head of the bed elevated 45 degrees.
B) sitting upright with the arms supported on an overbed table.
C) on the left side with the right arm extended above the head.
D) in Trendelenburg's position with both arms extended.

Question 9

The nurse is observing a student who is auscultating a patient's lungs. Which action by the student indicates that the nurse should intervene?

A) The student compares breath sounds from side to side.
B) The student starts at the base of the posterior lung and moves to the apices.
C) The student places the stethoscope over the scapulae and then auscultates.
D) The student listens only over the posterior part of the chest.

Question 10

When assessing the respiratory system of a 78-year-old patient, which of these data indicate that the nurse should take immediate action?

A) The chest appears barrel shaped.
B) The patient has a weak cough effort.
C) Crackles are audible in the lower two thirds of the posterior chest.
D) Hyperresonance is present across both sides of the chest.

Question 11

A patient with COPD has a "barrel chest." The nurse would expect the chest x-ray report to indicate that there is

A) overinflation of the alveoli.
B) consolidation of lung tissue.
C) fluid in the alveoli.
D) air in the pleural space.

Question 12

A patient with COPD is admitted to the hospital with dyspnea and a cough producing yellow sputum. When palpating the patient's thorax, the nurse will expect to find that chest expansion is

A) diminished.
B) asymmetric.
C) normal.
D) increased.

Question 13

When performing an assessment of the patient's respiratory system, the nurse uses the following illustrated technique to evaluate

A) chest expansion.
B) tactile fremitus.
C) accessory muscle use.
D) diaphragmatic excursion.

Question 14

In reviewing the results of a patient's pulmonary function test, the nurse recognizes that a patient with COPD is likely to have an increased

A) forced vital capacity.
B) peak expiratory flow.
C) tidal volume.
D) residual volume.

Question 15

A patient is admitted with a metabolic acidosis of unknown origin. Based on this diagnosis, the nurse would expect the patient to have

A) Kussmaul's respirations.
B) slow, shallow respirations.
C) a low oxygen saturation (SpO₂).
D) a decrease in PVO₂.

Question 16

A patient in respiratory distress is admitted to the medical unit at the hospital. During the initial assessment of the patient, the nurse should

A) obtain a comprehensive health history to determine the extent of any prior respiratory problems.
B) complete a full physical examination to determine the systemic effect of the respiratory distress.
C) delay the physical assessment and ask family members about any history of respiratory problems.
D) perform a respiratory system assessment and ask specific questions about this episode of respiratory distress.

Question 17

While caring for a patient with respiratory disease, the nurse observes that the patient's SpO₂ drops from 94% to 85% when the patient ambulates in the hall. The nurse determines that

A) supplemental oxygen should be used whenever the patient exercises.
B) arterial blood gas analysis should be done to verify the patient's SpO₂.
C) the response is normal and the patient should continue at this activity level.
D) the patient activity should be limited until the disease process is resolved.

Question 18

On auscultation of a patient's lungs, the nurse hears short, high-pitched sounds just before the end of inspiration in the right and left lower lobes. The nurse records this finding as

A) abnormal lung sounds in the bases of both lungs.
B) inspiratory wheezes in both lungs.
C) crackles in the right and left lower lobes.
D) pleural friction rub in the right and left lower lobes.

Question 19

A hypothermic patient is admitted to the emergency department, and pulse oximetry (SpO₂) indicates that the O₂ saturation is 95%. Which action should the nurse take next?

A) Complete a head-to-toe assessment.
B) Place the patient on high-flow oxygen.
C) Start rewarming the patient.
D) Obtain arterial blood gases (ABG).

Question 20

A patient who has a 30-pack-year history of smoking asks the nurse, "How does smoking really harm my lungs?" The nurse's response will be based on the effect of smoking on

A) cough and gag reflexes.
B) mucociliary clearance.
C) reflex bronchoconstriction.
D) the filtration of inspired air.

Question 21

The nurse is admitting a patient who has a diagnosis of an acute asthma attack. Which information obtained by the nurse indicates that the patient may need teaching regarding medication use?

A) The patient has been using the albuterol (Proventil) inhaler more frequently over the last 4 days.
B) The patient became very short of breath an hour before coming to the hospital.
C) The patient has been taking acetaminophen (Tylenol) 650 mg every 6 hours for chest-wall pain.
D) The patient says there have been no acute asthma attacks during the last year.

Question 22

A patient is admitted to the emergency department complaining of sudden onset shortness of breath and diagnosed with a possible pulmonary embolus. To confirm the diagnosis, the nurse will anticipate preparing the patient for a

A) chest x-ray.
B) spiral CT scan.
C) bronchoscopy.
D) PET scan.

Question 23

A patient with chronic hypoxemia (SaO₂ levels of 89%-90%) caused by COPD has just been admitted with increasing shortness of breath. In planning for discharge, which of these actions by the nurse will be most effective in improving compliance with discharge teaching?

A) Have the patient repeat the instructions immediately after the teaching.
B) Arrange for the patient's spouse to be present during the teaching.
C) Accomplish the patient teaching just before the scheduled discharge.
D) Start giving the patient discharge teaching on the day of admission.

Question 24

A patient is scheduled for a spiral CT scan to rule out a pulmonary embolus. Which information obtained by the nurse is most important to communicate to the health care provider before the examination?

A) The apical pulse is irregular.
B) The oxygen saturation is 93%.
C) The patient is allergic to shellfish.
D) The patient is very tachypneic.