Deck 16: Lungs and Thorax

Question 1

The nurse is preparing to assess a patient suspected of having orthopnea. Which question should the nurse include in the assessment?

A) "Are you able to carry out your routine activities without a change in breathing?"
B) "Do you prop yourself up on pillows when you sleep?"
C) "Do you breathe through your mouth or nose?"
D) "Can you describe your breathing during vigorous exercise?"

Answer 1

"Do you prop yourself up on pillows when you sleep?"

Question 2

The educator has reviewed the respiratory system for a nurse. Which statement made by the nurse indicates further teaching is required?

A) "The left main bronchus is shorter."
B) "The bronchi begin at the level of the sternal angle."
C) "The bronchi divide within each lobe of the lung."
D) "The bronchi warm and moisten air."

Answer 2

"The left main bronchus is shorter."

Question 3

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

A) The nurse should place a hand on the client's chest to count respirations.
B) The nurse should inform the client that they are preparing to count the client's respirations.
C) The nurse should count when the respirations are audible.
D) The nurse should count the respirations in an unobtrusive manner without informing the client.

Answer 3

The nurse should count the respirations in an unobtrusive manner without informing the client.

Question 4

The educator is observing the nurse's technique for a lung assessment. Which should the educator recognize demonstrates appropriate technique?

A) Auscultation begins from the base to apices of lungs.
B) Auscultation up one side of the thorax and then up the other.
C) Auscultation down one side of the thorax and then down the other.
D) Auscultation bilaterally from one side to the other.

Question 5

Which is the primary landmark used to identify and locate all of the other landmarks on the anterior chest?

A) Sternum.
B) Manubrium.
C) Suprasternal notch.
D) Angle of Louis.

Question 6

The nurse is preparing to auscultate the client's chest. Which anatomical location should the nurse place the stethoscope to auscultate tracheal breath sounds?

A) Below the xyphoid process.
B) Above the substernal notch.
C) Below the manubrium.
D) Between the substernal notch and manubrium.

Question 7

The nurse is reviewing the records of a client with severe left pleural effusion. Which assessment finding should the nurse anticipate? Select all that apply.

A) Absent breath sounds on the left side.
B) Tracheal shift to the right.
C) Hyperresonance upon percussion.
D) Bronchial breath sounds on the right side.
E) Pleural friction rub.

Question 8

The nurse is preparing to identify the angle of Louis prior to a thoracic assessment. Which landmark should the nurse use to identify this structure?

A) Clavicle.
B) Sternum.
C) First rib.
D) Vertebral column.

Question 9

The nurse is assessing the costal angle during the anterior inspection of the thorax. Which findings should the nurse anticipate?

A) 10°.
B) 30°.
C) 60°.
D) 90°.

Question 10

The nurse is assessing the client's respiratory pattern and notes periods of deep breathing alternating with periods of apnea. Which terminology should the nurse use to document the findings?

A) Tachypnea.
B) Obstructive breathing.
C) Hypoventilation.
D) Cheyne-Stokes.

Question 11

The nurse auscultating a client's lungs notes there is a low-pitched, continuous respiratory sounds that has a snoring quality. Which terminology should the nurse use to document the finding?

A) Rales.
B) Crackles.
C) Rhonchi.
D) Wheezes.

Question 12

The nurse reviewing a client's record notes that the client has a fractured floating rib. Which rib should the nurse identify has been fractured?

A) 1st.
B) 5th.
C) 9th.
D) 12th.

Question 13

The nurse is caring for a client that has been treated for asthma and is currently breathing shallow and trembling. Which action should the nurse take to help decrease the client's level of anxiety prior to assessing the client?

A) The nurse should explain all procedures in a calm and reassuring voice.
B) Request the immediate presence of the healthcare provider.
C) Provide oxygen for the client.
D) Delay the assessment until the client calms down.

Question 14

The nurse assessing the voice sounds of a client notes that the sounds are louder over the right lower lung lobe. Which should the nurse suspect the client is experiencing?

A) Atelectasis.
B) Lobar pneumonia.
C) Asthma.
D) Pleural effusion.

Question 15

A client asks the nurse why they are being evaluated for weight loss during a respiratory assessment. Which response should the nurse provide the client as the primary reason weight loss is assessed?

A) "Weight loss reflects poor nutrition which may affect the strength of respiratory muscles."
B) "Weight loss may have occurred as a result of lung or other diseases.
C) "Weight loss may be associated with poor nutrition which may interfere with the exchange of oxygen and carbon dioxide."
D) "Weight loss may be associated with nutritional deficiencies and places you at risk for respiratory infections."

Question 16

The nurse identifies abnormal breath sounds during an assessment. Which sounds should the nurse document as abnormal? Select all that apply.

A) Crackles.
B) Vesicular.
C) Bronchovesicular.
D) Wheezes.
E) Bronchial.

Question 17

The nurse notes movement on one side of the chest while palpating respiratory expansion. Which conditions should the nurse suspect is associated with this assessment finding? Select all that apply.

A) Atelectasis.
B) Chronic bronchitis.
C) Lobar pneumonia.
D) Pleural effusion.
E) Congestive heart failure.

Question 18

The nurse notes the client's respiration rate is 14 per minute and the expiration phase is the same length as the end-inspiration phase. Which term should the nurse use to document the findings?

A) Obstructive breathing.
B) Bradypnea.
C) Respiratory distress.
D) Eupnea.

Question 19

The nurse is preparing to auscultate the apex of the client's right lung. Which anatomical location should the nurse place the stethoscope?

A) Intercostal space sixth rib near the sternum.
B) Intercostal space fourth rib near the axillary line.
C) Below the scapula.
D) Near the right clavicle.

Question 20

The nurse is preparing to assess the client's respiratory system. Which order should the nurse conduct the assessment?

A) Auscultation.
B) Inspection.
C) Percussion.
D) Client survey.
E) Palpation.

Question 21

The nurse is caring for a client with increased cranial pressure. Which respiratory pattern should the nurse expect?

A) Cheyne-Stokes.
B) Hyperventilation.
C) Biot's respirations.
D) Bradypnea.

Question 22

The nurse is preparing to assess a client with scoliosis. Which assessment findings should the nurse anticipate?

A) An exaggerated posterior curvature of the thoracic spine.
B) A lateral curvature and rotation of the thoracic and lumbar spine.
C) Forward displacement of the sternum with depression of the adjacent costal cartilage.
D) Depression of the sternum and the adjacent costal cartilage.

Question 23

The nurse is preparing to assess for fremitus in a client. Which factor should the nurse recognize may result in absent fremitus?

A) Obesity.
B) Loud voice.
C) Sinus infection.
D) Cardiac arrhythmias.

Question 24

The nurse is reviewing the records of a client with chronic bronchitis. Which assessment finding should the nurse anticipate?

A) Fever.
B) Decreased respiratory rate.
C) Use of accessory muscles.
D) Dry cough.

Question 25

The nurse is preparing to auscultate the bronchovesicular sounds of a client. Which landmark should the nurse use to identify the correct placement of the stethoscope?

A) Anterior of the angle of Louis and lateral of the sternum in the second intercostal space.
B) Second and third intercostal spaces between scapulae.
C) Next to the trachea superior in each clavicle and in the first intercostal space.
D) Superiorly to the manubrium and anterior midclavicular.

Question 26

The nurse is preparing to auscultate the breath sounds of a client with asthma. Which breath sounds does the nurse anticipate to find upon assessment?

A) High pitch continuous sounds on inspiration and expiration.
B) Low pitch continuous rattling on inspiration and expiration.
C) High pitched short crackling.
D) Low pitched grating and rubbing on inhalation and exhalation.

Question 27

The nurse is preparing to assess a client with atelectasis. Which objective finding should the nurse anticipate?

A) Clubbing of the fingers.
B) Decreased or absent breath over the affected area.
C) No voice transmission.
D) Decreased chest wall expansion on the affected side.

Question 28

The nurse is auscultating tracheal breath sounds. Which should the nurse anticipate the normal findings to sound like?

A) Medium in loudness and pitch.
B) Soft and low pitched.
C) Harsh and high pitched.
D) Loud high pitched sounds.

Question 29

The nurse notes a client has a barrel chest. Which question should the nurse ask the client?

A) "Do you have a history of pneumonia?"
B) "Do you have a history of emphysema?"
C) "Have you ever been exposed to tuberculosis?"
D) "Have you ever been diagnosed with scoliosis?"