Deck 34: Assessing the Respiratory System

Question 1

The nurse notes that a patient with a head cold has a change in speech tone and volume. What should the nurse consider as being the reason for this observation?

A) The patient has been sneezing because of the cold.
B) The patient has been coughing because of the cold.
C) The cold is raising the patient's body temperature.
D) The sinuses play a role in speech.

Answer 1

The sinuses play a role in speech.

Question 2

The nurse is auscultating a patient's lung sounds. Where should the nurse expect to hear bronchial sounds? Place an X on the area in which these sounds should be heard.

Answer 2

Question 3

During a nap, the nurse notes that a patient's respirations periodically stop. How should the nurse document this finding?

A) tachypnea
B) bradypnea
C) apnea
D) atelectasis

Answer 3

apnea

Question 4

The nurse counts a patient's respirations at 30 per minute. From this finding, what about the patient's respiratory status should cause the nurse concern?

A) Pneumonia is developing.
B) Increased carbon dioxide in the blood is being expelled.
C) Respiratory arrest is beginning.
D) Pain is affecting the respiratory rate.

Question 5

During the assessment of a patient's respirations, the nurse observes the expiration phase as being almost twice as long as the inspiration phase. This finding is consistent with what condition?

A) chronic lung disease
B) heart failure
C) respiratory distress
D) normal respiration

Question 6

A trauma patient has no lung sounds in the oblique fissure, lower-left lobe, and base of the lung. Place an "X" over the area(s) the nurse is assessing.

Question 7

A patient's blood oxygen saturation level is 99% on room air. The nurse realizes that the oxygenated blood is transported to the heart through which structure?

A) pulmonary arteries
B) pulmonary veins
C) bronchial arteries
D) bronchial veins

Question 8

During pulmonary function tests, a patient is found to have approximately 500 mL of air moving in and out of the lungs during normal quiet breathing. The nurse realizes that this finding is considered the:

A) tidal volume.
B) expiratory reserve volume.
C) residual volume.
D) vital capacity.

Question 9

The nurse percusses hyperresonance over a patient's lungs. This finding is consistent with what health problem?

A) pneumonia
B) atelectasis
C) chronic asthma
D) pleural effusion

Question 10

The nurse is auscultating a patient's lungs. Which breath sounds should the nurse identify as being abnormal?

A) crackles
B) vesicular
C) bronchovesicular
D) wheezes
E) bronchial

Question 11

A patient is diagnosed with a low iron count. The nurse realizes that this patient might demonstrate signs of which of what health problem?

A) increased carbon dioxide in the blood
B) nausea
C) anxiety
D) poor tissue oxygenation

Question 12

A patient is diagnosed with a middle ear infection. The nurse realizes that which portion of the patient's airway is affected?

A) nasopharynx
B) oropharynx
C) laryngopharynx
D) nares

Question 13

During the assessment of a patient's voice sounds, the nurse hears increased and clear sounds over the patient's right lower lobe. This finding is consistent with which health problem?

A) emphysema
B) lobar pneumonia
C) asthma
D) pleural effusion

Question 14

During the palpation of a patient's chest for expansion, the nurse notices a decrease in expansion of the right side. This finding is consistent with what health problems?

A) emphysema
B) pneumonia
C) pleural effusion
D) heart failure
E) pneumothorax

Question 15

A patient is demonstrating poor exhalation. The nurse realizes that this patient is at risk for developing what health problem?

A) pleurisy
B) pulmonary edema
C) increased carbon dioxide levels
D) reduced oxygen capacity of red blood cells

Question 16

During the assessment of a patient's respiratory status, the nurse locates the manubrium and the body of the sternum. Which anatomical structure is the nurse assessing?

A) Adam's apple
B) Angle of Louis
C) intercostal space
D) xiphoid process

Question 17

During the assessment of a patient, the nurse locates the approximate position of the larynx. This can be found by identifying what body structure?

A) clavicle
B) Adam's apple
C) first rib
D) shoulder joint

Question 18

The nurse observes a patient breathing through an open mouth. Which function is being bypassed by mouth breathing?

A) cooling the air
B) neutralizing the air
C) filtering the air
D) separating the air

Question 19

During an assessment, a patient begins to cough. What should the nurse realize about this finding?

A) The patient has a cold.
B) The patient is nervous.
C) Something other than air was entering the larynx.
D) Something other than air was entering the epiglottis.

Question 20

During the assessment of a patient's nasal cavities, the nurse notes watery nasal discharge and pale turbinates. These findings are consistent with what health problem?

A) allergies
B) infection
C) cocaine use
D) sinus infection

Question 21

When preparing a patient for a pulmonary function test, what should the nurse instruct the patient about the process?

A) "Expect to be sedated for the test."
B) "Antinausea medication will be provided prior to the test."
C) "A nose clip will be worn during the test."
D) "Oxygen will be used for a while after the test."

Question 22

The nurse notes that a patient is susceptible to chronic pulmonary diseases. What did the nurse assess to make this clinical decision?

A) The patient owned and worked a farm.
B) The patient worked in a hospital.
C) The patient as an air traffic controller.
D) The patient played in a band.

Question 23

The nurse is planning a class for nursing assistants. What should the nurse include as causing interference with accurate pulse oximeter readings?

A) external light sources
B) nail polish
C) inhalation injuries
D) arterial pulses
E) placement on cartilage

Question 24

The nurse administers oxygen to a patient who has lost a moderate amount of blood following a motor vehicle accident. What is the primary reason for this intervention?

A) ease the work of breathing for the patient
B) compensate for the reduction in circulating oxygen
C) provide comfort during assessment
D) prevent shock from developing

Question 25

The nurse wants to assess the apex of a patient's right lung. In which location should the nurse place the stethoscope to assess this patient?

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 26

The nurse caring for an elderly patient realizes that the patient is at risk for problems related to the volume of air remaining in the lungs because of what physiological change?

A) Elasticity of lungs decreases with age.
B) Older adults have a more rapid respiratory rate.
C) There is a tightening of the diaphragm with age.
D) Intercostal muscles become weaker with age.

Question 27

The nurse is preparing to assess a patient with cystic fibrosis. What should the nurse keep in mind about this patient's health problem?

A) The patient will have difficulty speaking.
B) The patient will have cardiac dysrhythmias.
C) The patient is prone to respiratory infections.
D) The patient will have altered nutritional status.
E) The patient will have thick respiratory secretions.

Question 28

A patient suspected of having a lung mass asks why a positron emission tomography (PET) scan was ordered instead of a computed tomography (CT) scan. The nurse was present in the room when the physician discussed the test. What is the best response by the nurse?

A) "Your doctor prefers to order PET scans."
B) "Why are you concerned about this test?"
C) "PET scans focus on your particular problem."
D) "You will still need a CT scan also."

Question 29

A patient has the following arterial blood gas (ABG) results. In analyzing the data, the nurse recognizes the patient has what health problem? $$\begin{array} { | l | l | } \hline \begin{array} { l } \text { Arterial Blood } \\\text { Gas }\end{array} & \text { Patient Results } \\\hline \mathrm { pH } & 7.28 \\\hline \mathrm { PaCO } & 55 \mathrm { mmHg } \\\hline \mathrm { PaO } _ { 2 } & 75 \mathrm { mmHg } \\\hline \mathrm { HCO } _ { 3 } & 24 \mathrm { mEq } / \mathrm { L } \\\hline \mathrm { BE } & + 1 \mathrm { mEq } / \mathrm { L } \\\hline\end{array}$$

A) metabolic acidosis
B) metabolic alkalosis
C) respiratory acidosis
D) respiratory alkalosis

Question 30

A patient is recovering from a bronchoscopy. What care should the nurse provide to this patient?

A) Instruct the patient to avoid eating and drinking until the gag reflex returns.
B) Report dark blood-tinged respiratory secretions to the physician.
C) Notify the physician with any breathing difficulty.
D) Administer pain medications immediately following the procedure.
E) Instruct the patient on use of incentive spirometry to use following the procedure.

Question 31

Upon auscultation of the chest, the nurse reports to the preceptor what is heard. What statement should cause the preceptor to be most concerned?

A) "I heard crackles earlier, but now I am not able to hear anything."
B) "I hear wheezing in the right lobes, but clear on the left."
C) "There are coarse crackles that clear with coughing."
D) "The patient was clear, but now there are scattered wheezes bilaterally."

Question 32

While preparing a patient for a bronchoscopy, the nurse ensures the suction equipment is available. Why is the nurse taking this precaution?

A) There is a high risk of a reaction to medications used for sedation.
B) Laryngospasm and respiratory distress could follow this test.
C) Suction equipment should always be available.
D) Pulmonary embolus is a complication following this test.

Question 33

The nurse determines that a patient has bronchovesicular breath sounds. What criteria did the nurse use to make this clinical decision?

A) medium pitch
B) heard between the scapula
C) heard on each side of the sternum
D) inspiration lasts longer than expiration
E) inspiration and expiration equal in duration

Question 34

The nurse is instructing a patient on collecting a sputum sample. What is the best time for the nurse to collect this specimen?

A) after a meal
B) upon awakening from a nap
C) before a meal
D) upon awakening in the morning

Question 35

The nurse notes that a patient's respiratory rate and depth constantly change. What structures should the nurse recall are affecting this patient's respirations?

A) pons
B) aortic bodies
C) carotid bodies
D) medulla oblongata
E) number of alveoli

Question 36

A patient is scheduled to have a magnetic resonance imaging scan (MRI). What information is most important for the nurse to obtain before the procedure?

A) whether the patient is wearing any metal
B) when the patient last ate or drank
C) whether the patient is allergic to shellfish
D) whether the patient has any loose teeth

Question 37

The nurse is assessing an older patient's respiratory status. What factors related to aging can predispose this patient to pneumonia?

A) slower respiratory rate
B) less effective cough
C) immobility
D) increased pain response
E) fixed income

Question 38

A patient has the following pulmonary function test results. For which patient should the nurse identify these findings as being normal? $$\begin{array} { | l | l | } \hline \text { Pulmonary Function Test (PFT) } & \text { Patient Results } \\\hline \text { Inspiratory capacity } & 3600 \mathrm {~mL} \\\hline \text { Functional residual capacity } & 2600 \mathrm {~mL} \\\hline \text { Vital capacity } & 4600 \mathrm {~mL} \\\hline \text { Total lung capacity } & 5900 \mathrm {~mL} \\\hline\end{array}$$

A) a child
B) an adolescent
C) a middle-aged patient
D) an elderly patient

Question 39

A patient admitted with probable emphysema is scheduled for diagnostic tests. What test should the nurse expect to be prescribed to assess the patient's acid‒base balance?

A) bronchoscopy
B) sputum studies
C) pulse oximetry
D) arterial blood gases (ABGs)

Question 40

During an assessment the nurse becomes concerned about a patient's lung compliance. What factors about the patient's respiratory status causes the nurse to have this concern?

A) patency of the nares
B) flexibility of the rib cage
C) status of a sinus infection
D) elasticity of the lung tissue
E) pulse oximeter reading of 97%

Question 41

The nurse is counseling the family of a patient diagnosed with lung cancer about discharge instructions. The daughter remarks that the patient never smoked and wonders why the cancer occurred. What is the nurse's best response?

A) "It could have been caused by a high-sodium diet."
B) "Your father may not be telling the truth about smoking."
C) "There may have been a genetic predisposition."
D) "Be more concerned about caring for him than why it happened."

Question 42

During an assessment the nurse learns that a patient has an alteration in the sense of smell. What should the nurse consider as causes of this alteration?

A) rhinoplasty
B) zinc deficiency
C) deviated septum
D) olfactory nerve damage
E) chronic inflammation of the nose