Deck 17: Respiratory System

Question 1

The nurse is assessing a client with a severe left pleural effusion. Which assessment data does the nurse anticipate based on the client's diagnosis?

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

Answer 1

Absent breath sounds on the left side.
Tracheal shift to the right.
Pleural friction rub auscultated.

Question 2

The nurse wants to assess the apex of a client's right lung. Which locations should the nurse place the stethoscope to assess this area on the client?

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.

Answer 2

Near the right clavicle.

Question 3

The nurse documents that the client's respirations are shallow and rapid with a rate of 30 breaths per minute. Based on these assessment findings, which conclusion by the nurse is the most appropriate?

A) Client fatigue.
B) Client anxiety.
C) Normal client finding.
D) Client boredom.

Answer 3

Client anxiety.

Question 4

The client aspirated a pea during a meal. The healthcare provider notes that the pea is located in the bronchus. When educating the client regarding the location of the pea, which is the correct location for the nurse to use?

A) A.
B) B.
C) C.
D) D.

Question 5

The nurse is providing care to a client in the emergency department who received a breathing treatment earlier. The nurse is now preparing the client for a procedure and notes that the client is breathing in a shallow manner and the client's hands are trembling. Which action will help decrease the client's level of anxiety?

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) Postpone the procedure.

Question 6

The nurse is preparing to auscultate the client's chest. Where will the nurse place the stethoscope to auscultate tracheal breath sounds?

A) A.
B) B.
C) C.
D) D.

Question 7

The nurse is assessing the client and notes low-pitched, continuous respiratory sounds that have a snoring quality while auscultating the client's lungs. Which term would the nurse use when documenting this finding?

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

Question 8

The nurse percusses the lungs and determines that there is an area of hyperresonance. Based on this finding, which condition does the nurse suspect?

A) Pneumonia.
B) Atelectasis.
C) Pneumothorax.
D) Pleural effusion.

Question 9

While palpating respiratory expansion on a client the nurse notes movement on only one side of the chest. Which conditions are associated with this assessment finding?

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

Question 10

During the assessment of a client's voice sounds, the nurse hears louder sounds over the client's right lower lobe. The nurse suspects the client has which condition based on this assessment finding?

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

Question 11

The nurse is preparing to assess the client's respiratory system. Rank in order according to how the nurse should proceed. Standard Text: Click on the down arrow for each response in the right column and select the correct choice from the list.
Response

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

Question 12

During the respiratory assessment of a client the nurse wishes to locate the angle of Louis. Which landmarks will the nurse use to identify this structure?

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

Question 13

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 accurately.
B) The nurse should inform the client that the nurse is counting the client's respirations.
C) The nurse should count only the respirations that are audible.
D) The nurse should count the respirations in an unobtrusive manner without informing the client.

Question 14

The nurse auscultates the client's lungs and prepares to document the assessment. Which breath sounds are considered abnormal and may require further intervention?

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

Question 15

The nurse is conducting an assessment. Where is the right anterior axillary line (ALL) located?

A) A.
B) B.
C) C.
D) D.

Question 16

The nursing instructor is observing a student nurse assess the client's respiratory system. Which technique demonstrated by the student is the most appropriate?

A) From base to apices of lungs.
B) First up one side of the thorax, then up the other.
C) First down one side of the thorax, then down the other.
D) From side to side.

Question 17

The nurse is assessing the client's respiratory pattern and notes periods of deep breathing alternating with periods of apnea. When documenting this assessment finding, which term is the most appropriate for the nurse to use?

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

Question 18

While assessing the client, the nurse notes that the client has a productive cough. Based on this observation, which question is appropriate for the nurse to include in the focused interview?

A) "Have you been losing weight?"
B) "How long have you been sick?"
C) "Are you wheezing?"
D) "Are you coughing up any mucus or phlegm?"

Question 19

During the assessment of a client's respiratory system, the nurse determines that the client's expiration phase is the same length as the inspiration phase. The client's respiratory rate is 14 per minute. Which term will the nurse use to document this client finding in the medical record?

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

Question 20

While the client sleeps, the nurse notes that the client's respirations periodically stop. Which term will the nurse use to document this finding in the medical record?

A) Tachypnea.
B) Bradypnea.
C) Apnea.
D) Atelectasis.

Question 21

The client is 36 weeks pregnant. The nurse is assessing the client's respiratory system and finds that the respiratory rate is 24 breaths per minute. The client states that she sometimes experiences shortness of breath. Which response by the nurse is the most appropriate?

A) "You have developed asthma during your pregnancy."
B) "During your last trimester, it is normal for you to feel short of breath and to have a faster respiratory rate."
C) "I'm going to have to notify your healthcare provider right now about these findings."
D) "You have been infected with tuberculosis."

Question 22

A preschool client's respiratory rate is 30 per minute. The mother states, "That seems like a really high number. My healthcare provider told me my respiratory rate is only 16 per minute." Which response by the nurse is the most appropriate?

A) "This is a normal finding for your child's age."
B) "Your child is exhibiting a sign of a respiratory infection."
C) "Your child requires further assessment."
D) "Your child may simply be anxious."

Question 23

The nurse is assessing a 1-month-old infant's respiratory system and sees that the infant is primarily using abdominal muscles to breathe and has an irregular breathing pattern. Which conclusion by the nurse is appropriate based on this observation?

A) The infant is experiencing respiratory distress.
B) The infant has developed pneumonia.
C) The infant is exhibiting a normal respiratory pattern.
D) The infant has developed a pneumothorax.

Question 24

A client is experience tachypnea with anxiety and is "hyperventilating." Based on this assessment, which finding does the nurse anticipate for this client?

A) Pleuritic pain.
B) Congestive heart failure.
C) Increased carbon dioxide levels.
D) Reduced oxygen capacity.

Question 25

The nurse is preparing to assess an older adult client diagnosed with emphysema. Which anatomical change does the nurse anticipate when performing this client's assessment?

A) Funnel chest.
B) Barrel chest.
C) Pigeon chest.
D) Scoliosis.

Question 26

The nurse is caring for an adolescent client who is hospitalized with asthma. Several peers are preparing to visit the client and have brought gifts. Which gift will the nurse prevent from being placed in the client's room?

A) Magazines.
B) Candy.
C) MP3 player.
D) Fresh flowers.

Question 27

As the nurse assesses the pregnant client, the client states that she sometimes feels like she has difficulty breathing. The client has reached the 36th week of her pregnancy. Which is the reason that the client is experiencing this phenomenon?

A) The fetus is pushing the diaphragm upwards.
B) Fatigue due to the pregnancy.
C) Anxiety about her impending delivery.
D) Contractions.

Question 28

The nurse is percussing the anterior chest of an older adult client. Which finding does the nurse anticipate for this client based on the age?

A) Flatness.
B) Dullness.
C) Tympany.
D) Hyperresonance.

Question 29

The nurse is examining an African American client. When compared to Caucasian client, which conditions is this client at a higher risk for developing?

A) Asthma.
B) Sarcoidosis.
C) Tuberculosis.
D) Obstructive sleep apnea.
E) Chronic bronchitis.

Question 30

A client with chronic bronchitis is admitted to the hospital. The nurse inspects the client while assessing the client's respiratory system. Which assessment finding is expected?

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

Question 31

The nurse is preparing an educational program regarding Healthy People 2020. Which pieces of information are important to include for caregivers of infants and young children?

A) "Infants should always be placed to sleep on their sides."
B) "Children should be taught to wash their hands."
C) "Caregivers should ensure that the children's toys are age-appropriate."
D) "Parents should be encouraged to avoid immunizations."
E) "Caregivers should inspect the children's toys for small possibly inhalable parts."