Question 1

The nurse is admitting a client with acute shortness of breath. Which of the following actions should the nurse take during the initial assessment of the client?

Accepted Answer

When a client has severe respiratory distress, only information pertinent to the current episode is obtained, and a more thorough assessment is deferred until later. Obtaining a comprehensive health history or full physical examination is unnecessary until the acute distress has resolved. A focused physical assessment should be done rapidly to help determine the cause of the distress and suggest treatment. Although family members may know about the client's history of medical problems, the client is the best informant for these data.

Question 2

Which of the following actions should the nurse plan to take for a client who is scheduled for pulmonary function testing (PFT)?

Accepted Answer

For PFT, the client should inhale deeply and exhale as long, hard, and fast as possible. The other actions are not needed with PFT.

Question 3

The nurse is admitting a client to the emergency department who has sudden onset shortness of breath and diagnosed with a possible pulmonary embolus. To confirm the diagnosis, which of the following diagnostic measures should the nurse anticipate?

Accepted Answer

Spiral CT scans are the most commonly used test to diagnose pulmonary emboli. A chest x-ray may be ordered but will not be diagnostic for a pulmonary embolus. Bronchoscopy is used to inspect for changes in the bronchial tree, not to assess for vascular changes. PET scans are most useful in determining the presence of malignancy.

Question 4

The nurse is auscultating a client's chest while the client takes a deep breath and hears loud, high-pitched, "blowing" sounds at both lung bases. Which of the following information should the nurse document?

Accepted Answer

The description indicates that the nurse hears bronchial breath sounds that are abnormal when heard in the peripheral lung fields. Adventitious sounds are extra breath sounds such as crackles, wheezes, rhonchi, and friction rubs. Vesicular sounds are low-pitched, soft sounds heard over all lung areas except the major bronchi.

Question 5

The nurse is caring for a client with respiratory disease and observes that the client's SpO₂ drops from 92% to 88% while the client is ambulating in the hallway. Which of the following actions should the nurse take next?

Accepted Answer

The drop in SpO₂ to 85% indicates that the client is hypoxemic and needs supplemental oxygen when exercising. The other actions also are appropriate, but the first action should be to correct the hypoxemia.

Question 6

The nurse is observing a student who is listening to a client's lungs. Which of the following actions by the student indicates a need to review respiratory assessment skills?

Accepted Answer

The stethoscope should be placed over lung tissue, not over bony structures. Breath sounds should be compared from side to side. The techniques of starting at the lung base and then moving toward the apices and listening only over the posterior chest are acceptable.

Question 7

The nurse is analyzing the results of a client's arterial blood gases (ABGs). Which of the following findings require the most immediate action?

Accepted Answer

All the values are abnormal, but the low PaO₂ indicates that the client is at the point on the oxyhemoglobin dissociation curve where a small change in the PaO₂ will cause a large drop in the O₂ saturation and a decrease in tissue oxygenation. The nurse should intervene immediately to improve the client's oxygenation.

Question 8

The nurse is reviewing a client's laboratory results and identifies which of the following values as a normal tidal volume?

Accepted Answer

The normal tidal volume is 500 mL.

Question 9

The nurse is palpating the posterior chest of a client while the client says "99" and notes that no vibration is felt. Which of the following information should the nurse document?

Accepted Answer

To assess for tactile fremitus, the nurse should use the palms of the hands to assess for vibration when the client repeats a word or phrase such as "99." Different techniques are used to assess for dullness to percussion, decreased breath sounds, and diminished expansion.

Question 10

The nurse is assessing a client with chronic obstructive pulmonary disease (COPD) with increasing dyspnea over the last 3 days. Which of the following findings is most important to report to the health care provider?

Accepted Answer

The increase in respiratory rate indicates respiratory distress and a need for rapid interventions such as administration of oxygen or medications. The other findings are common chronic changes occurring in clients with COPD.

Question 11

The nurse is caring for a client with a chronic cough who has had a bronchoscopy. Which of the following actions should the nurse include in the nursing care plan after the procedure?

Accepted Answer

Because a local anaesthetic is used to suppress the gag or cough reflexes during bronchoscopy, the nurse should monitor for the return of these reflexes before allowing the client to take oral fluids or food. Blood-tinged mucus is not uncommon after bronchoscopy. The client does not need to be on bed rest, and the head of the bed does not need to be in the high Fowler's position.

Question 12

Which of the following lung structures has the most generations?

Accepted Answer

The lung structure that has the most generations is the alveoli with 28. Segmental bronchi, subsegmental bronchi, and bronchioles have less than 28 generations.

Question 13

The nurse is caring for a client with a metabolic acidosis of unknown origin. Which of the following findings should the nurse expect based on this diagnosis?

Accepted Answer

Kussmaul's (deep and rapid) respirations are a compensatory mechanism for metabolic acidosis. Intercostal retractions, a low oxygen saturation rate, and a decrease in PvO2 would not be caused by acidosis.

Question 14

The nurse is assessing the respiratory system of an older-adult client. Which of the following findings indicate that the nurse should take immediate action?

Accepted Answer

Crackles in the lower half of the lungs indicate that the client may have an acute problem such as heart failure. The nurse should immediately accomplish further assessments, such as oxygen saturation, and notify the health care provider. A barrel-shaped chest,
hyper-resonance to percussion, and a weak cough effort are associated with aging. Further evaluation may be needed, but immediate action is not indicated.

Question 15

After the nurse has received change-of-shift report, which of the following clients should be assessed first?

Accepted Answer

Since the cough and gag are decreased after bronchoscopy, this client should be assessed for airway maintenance. The other clients do not have clinical manifestations or procedures that require immediate assessment by the nurse.

Question 16

The nurse is auscultating a client's lungs and hears short, high-pitched sounds during exhalation in the lower 1/3 of both lungs. Which of the following information should the nurse document?

Accepted Answer

Wheezes are high-pitched sounds. In this case they are heard during the expiratory phase of the respiratory cycle. Abnormal breath sounds are either bronchial or bronchovesicular sounds heard in the peripheral lung fields. Crackles are low-pitched, "bubbling" sounds. Pleural friction rubs are grating sounds that are usually heard during both inspiration and expiration.

Question 17

The nurse is admitting a client who is hypothermic with a O2 saturation of 96%. Which of the following actions should the nurse take next?

Accepted Answer

Although the O2 saturation is adequate, the left shift in the oxyhemoglobin dissociation curve will decrease the amount of oxygen delivered to tissues, so high oxygen concentrations should be given until the client is normothermic. The other actions also are appropriate, but the initial action should be to administer oxygen.

Question 18

The nurse has just received arterial blood gas (ABG) results on four clients. Which of the following results is considered normal?

Accepted Answer

These ABGs indicate normal values.

Question 19

Which of the following pH values is abnormal for a pH when assessing blood results of a mixed venous blood sample?

Accepted Answer

The normal pH of a mixed venous sample is 7.31-7.41. The normal pH of an arterial blood sample is 7.35-7.45.

Question 20

The nurse is preparing a client with a right-sided pleural effusion for a thoracentesis. Which of the following positions should the nurse position the client?

Accepted Answer

The upright position with the arms supported increases lung expansion, allows fluid to collect at the lung bases, and expands the intercostal space so that access to the pleural space is easier. The other positions would increase the work of breathing for the client and make it more difficult for the health care provider performing the thoracentesis.

Quiz 28: Nursing Assessment Respiratory System

The nurse is admitting a client with acute shortness of breath. Which of the following actions should the nurse take during the initial assessment of the client?

Which of the following actions should the nurse plan to take for a client who is scheduled for pulmonary function testing (PFT) ?

The nurse is admitting a client to the emergency department who has sudden onset shortness of breath and diagnosed with a possible pulmonary embolus. To confirm the diagnosis, which of the following diagnostic measures should the nurse anticipate?

The nurse is auscultating a client's chest while the client takes a deep breath and hears loud, high-pitched, "blowing" sounds at both lung bases. Which of the following information should the nurse document?

The nurse is caring for a client with respiratory disease and observes that the client's SpO₂ drops from 92% to 88% while the client is ambulating in the hallway. Which of the following actions should the nurse take next?

The nurse is observing a student who is listening to a client's lungs. Which of the following actions by the student indicates a need to review respiratory assessment skills?

The nurse is analyzing the results of a client's arterial blood gases (ABGs) . Which of the following findings require the most immediate action?

The nurse is reviewing a client's laboratory results and identifies which of the following values as a normal tidal volume?

The nurse is palpating the posterior chest of a client while the client says "99" and notes that no vibration is felt. Which of the following information should the nurse document?

The nurse is assessing a client with chronic obstructive pulmonary disease (COPD) with increasing dyspnea over the last 3 days. Which of the following findings is most important to report to the health care provider?

The nurse is caring for a client with a chronic cough who has had a bronchoscopy. Which of the following actions should the nurse include in the nursing care plan after the procedure?

Which of the following lung structures has the most generations?

The nurse is caring for a client with a metabolic acidosis of unknown origin. Which of the following findings should the nurse expect based on this diagnosis?

The nurse is assessing the respiratory system of an older-adult client. Which of the following findings indicate that the nurse should take immediate action?

After the nurse has received change-of-shift report, which of the following clients should be assessed first?

The nurse is auscultating a client's lungs and hears short, high-pitched sounds during exhalation in the lower 1/3 of both lungs. Which of the following information should the nurse document?

The nurse is admitting a client who is hypothermic with a O2 saturation of 96%. Which of the following actions should the nurse take next?

The nurse has just received arterial blood gas (ABG) results on four clients. Which of the following results is considered normal?

Which of the following pH values is abnormal for a pH when assessing blood results of a mixed venous blood sample?

The nurse is preparing a client with a right-sided pleural effusion for a thoracentesis. Which of the following positions should the nurse position the client?

Quiz 28: Nursing Assessment Respiratory System

The nurse is admitting a client with acute shortness of breath. Which of the following actions should the nurse take during the initial assessment of the client?

Which of the following actions should the nurse plan to take for a client who is scheduled for pulmonary function testing (PFT) ?

The nurse is admitting a client to the emergency department who has sudden onset shortness of breath and diagnosed with a possible pulmonary embolus. To confirm the diagnosis, which of the following diagnostic measures should the nurse anticipate?

The nurse is auscultating a client's chest while the client takes a deep breath and hears loud, high-pitched, "blowing" sounds at both lung bases. Which of the following information should the nurse document?

The nurse is caring for a client with respiratory disease and observes that the client's SpO2 drops from 92% to 88% while the client is ambulating in the hallway. Which of the following actions should the nurse take next?

The nurse is observing a student who is listening to a client's lungs. Which of the following actions by the student indicates a need to review respiratory assessment skills?

The nurse is analyzing the results of a client's arterial blood gases (ABGs) . Which of the following findings require the most immediate action?

The nurse is reviewing a client's laboratory results and identifies which of the following values as a normal tidal volume?

The nurse is palpating the posterior chest of a client while the client says "99" and notes that no vibration is felt. Which of the following information should the nurse document?

The nurse is assessing a client with chronic obstructive pulmonary disease (COPD) with increasing dyspnea over the last 3 days. Which of the following findings is most important to report to the health care provider?

The nurse is caring for a client with a chronic cough who has had a bronchoscopy. Which of the following actions should the nurse include in the nursing care plan after the procedure?

Which of the following lung structures has the most generations?

The nurse is caring for a client with a metabolic acidosis of unknown origin. Which of the following findings should the nurse expect based on this diagnosis?

The nurse is assessing the respiratory system of an older-adult client. Which of the following findings indicate that the nurse should take immediate action?

After the nurse has received change-of-shift report, which of the following clients should be assessed first?

The nurse is auscultating a client's lungs and hears short, high-pitched sounds during exhalation in the lower 1/3 of both lungs. Which of the following information should the nurse document?

The nurse is admitting a client who is hypothermic with a O2 saturation of 96%. Which of the following actions should the nurse take next?

The nurse has just received arterial blood gas (ABG) results on four clients. Which of the following results is considered normal?

Which of the following pH values is abnormal for a pH when assessing blood results of a mixed venous blood sample?

The nurse is preparing a client with a right-sided pleural effusion for a thoracentesis. Which of the following positions should the nurse position the client?

The nurse is caring for a client with respiratory disease and observes that the client's SpO₂ drops from 92% to 88% while the client is ambulating in the hallway. Which of the following actions should the nurse take next?