Chapter 26: Nursing Assessment: Respiratory System My Nursing Test Banks

Lewis: Medical-Surgical Nursing, 8th Edition

Chapter 26: Nursing Assessment: Respiratory System

Test Bank

MULTIPLE CHOICE

1. A patient with acute shortness of breath is admitted to the hospital. Which action should the nurse take during the initial assessment of the patient?

a.

Complete a full physical examination to determine the systemic effect of the respiratory distress.

b.

Obtain a comprehensive health history to determine the extent of any prior respiratory problems.

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.

ANS: D

When a patient 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 patients history of medical problems, the patient is the best informant for these data.

DIF: Cognitive Level: Application REF: 504

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

2. When preparing the patient with a right-sided pleural effusion for a thoracentesis, how will the nurse position the patient?

a.

Supine with the head of the bed elevated 45 degrees

b.

In the Trendelenburg position with both arms extended

c.

On the left side with the right arm extended above the head

d.

Sitting upright with the arms supported on an over bed table

ANS: D

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 patient and make it more difficult for the health care provider performing the thoracentesis.

DIF: Cognitive Level: Comprehension REF: 516

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

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

a.

intercostal retractions.

b.

Kussmaul respirations.

c.

a low oxygen saturation (SpO2).

d.

a decrease in venous O2 pressure.

ANS: B

Kussmaul (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.

DIF: Cognitive Level: Application REF: 511

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

4. On auscultation of a patients lungs, the nurse hears short, high-pitched sounds during exhalation in the lower 1/3 of both lungs. The nurse records this finding as

a.

expiratory crackles at the bases.

b.

expiratory wheezes in both lungs.

c.

abnormal lung sounds in the bases of both lungs.

d.

pleural friction rub in the right and left lower lobes.

ANS: B

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.

DIF: Cognitive Level: Comprehension REF: 511

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

5. The nurse palpates the posterior chest while the patient says 99 and notes that no vibration is felt. How should this be charted?

a.

Diminished expansion

b.

Dullness to percussion

c.

Absent tactile fremitus

d.

Decreased breath sounds

ANS: C

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

DIF: Cognitive Level: Comprehension REF: 508

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

6. A patient with a chronic cough has a bronchoscopy. Which action will be included in the nursing care plan after the procedure?

a.

Elevate the head of the bed to 80 to 90 degrees.

b.

Keep the patient NPO until the gag reflex returns.

c.

Place on bed rest for at least 4 hours postbronchoscopy.

d.

Notify the health care provider about blood-tinged mucus.

ANS: B

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

DIF: Cognitive Level: Application REF: 514 | 515 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

7. When auscultating a patients 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.

normal sounds.

b.

vesicular sounds.

c.

abnormal sounds.

d.

adventitious sounds.

ANS: C

The description indicates that the nurse hears bronchial breath sounds that are abnormal when heard at the lung base. 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.

DIF: Cognitive Level: Comprehension REF: 510

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

8. While caring for a patient with respiratory disease, the nurse observes that the patients SpO2 drops from 92% to 88% while the patient is ambulating in the hallway. Which action should the nurse take next?

a.

Notify the health care provider.

b.

Document the response to exercise.

c.

Administer the PRN supplemental O2.

d.

Encourage the patient to pace activity.

ANS: C

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

DIF: Cognitive Level: Application REF: 501

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

9. Which action will the nurse plan to take for a patient who is scheduled for pulmonary function testing (PFT)?

a.

Explain reasons for NPO status.

b.

Administer sedative drug before PFT.

c.

Assess pulse and BP after the procedure.

d.

Teach deep inhalation and forceful exhalation.

ANS: D

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

DIF: Cognitive Level: Application REF: 514 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

10. The nurse is observing a student who is listening to a patients lungs. Which action by the student indicates a need to review respiratory assessment skills?

a.

The student compares breath sounds from side to side.

b.

The student listens only over the posterior part of the chest.

c.

The student places the stethoscope over the scapulae and then auscultates.

d.

The student starts at the base of the posterior lung and moves to the apices.

ANS: C

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.

DIF: Cognitive Level: Comprehension REF: 509-510

TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment

11. A patient with chronic hypoxemia (SaO2 levels of 89% to 90%) caused by chronic obstructive pulmonary disease (COPD) has been hospitalized 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.

Arrange for the patients spouse to be present during the teaching.

b.

Start giving the patient discharge teaching on the day of admission.

c.

Accomplish the patient teaching just before the scheduled discharge.

d.

Have the patient repeat the instructions immediately after the teaching.

ANS: A

Hypoxemia interferes with the patients ability to learn and retain information, so having the patients spouse present will increase the likelihood that discharge instructions will be followed. Having the patient repeat the instructions will indicate that the information is understood at the time, but it does not guarantee retention of the information. Because the patient is likely to be distracted just before discharge, giving discharge instructions just before discharge is not ideal. The patient is likely to be anxious and even more hypoxemic than usual on the day of admission, so teaching about discharge should be postponed.

DIF: Cognitive Level: Application REF: 507 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

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

a.

positron emission tomography (PET) scan.

b.

chest x-ray.

c.

bronchoscopy.

d.

spiral computed tomography (CT) scan.

ANS: D

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.

DIF: Cognitive Level: Comprehension REF: 514 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

13. 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 says there have been no acute asthma attacks during the last year.

b.

The patient became very short of breath an hour before coming to the hospital.

c.

The patient has been using the albuterol (Proventil) inhaler more frequently over the last 4 days.

d.

The patient has been taking acetaminophen (Tylenol) 650 mg every 6 hours for chest-wall pain.

ANS: C

The increased need for a rapid acting bronchodilator should alert the patient that an acute attack may be imminent and that a change in therapy may be needed. The patient should be taught to contact a health care provider if this occurs. The other data do not indicate any need for additional teaching.

DIF: Cognitive Level: Application REF: 506

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

14. A patient with acute dyspnea is scheduled for a spiral computed tomography (CT) scan. Which information obtained by the nurse is most important to communicate to the health care provider before the CT?

a.

The apical pulse is 102.

b.

The respiratory rate is 32.

c.

The oxygen saturation is 93%.

d.

The patient is allergic to shellfish.

ANS: D

Because the contrast solution used during a spiral CT is iodine-based, the patient may need to have the CT scan without contrast or be premedicated before contrast injection. The increased pulse, oxygen saturation, and tachypnea all need further assessment or intervention but do not indicate a need to modify the CT procedure.

DIF: Cognitive Level: Application REF: 513

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

15. When the nurse is analyzing the results of a patients arterial blood gases (ABGs), which finding indicates the need for most immediate action?

a.

The arterial oxygen saturation (SaO2) is 92%.

b.

The partial pressure of oxygen in arterial blood (PaO2) is 59 mm Hg.

c.

The partial pressure of CO2 in arterial blood (PaCO2) is 31 mm Hg.

d.

The bicarbonate level (HCO3) is 29 mEq/L.

ANS: B

All the values are abnormal, but the low PaO2 indicates that the patient 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 patients oxygenation.

DIF: Cognitive Level: Application REF: 501

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

16. When assessing the respiratory system of a 78-year-old patient, which finding indicates that the nurse should take immediate action?

a.

The chest appears barrel shaped.

b.

The patient has a weak cough effort.

c.

Crackles are heard from the lung bases to the midline.

d.

Hyperresonance is present across both sides of the chest.

ANS: C

Crackles in the lower half of the lungs indicate that the patient 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, hyperresonance to percussion, and a weak cough effort are associated with aging. Further evaluation may be needed, but immediate action is not indicated.

DIF: Cognitive Level: Application REF: 503-504

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

17. A hypothermic patient is admitted to the emergency department, and pulse oximetry (SpO2) indicates that the O2 saturation is 96%. Which action should the nurse take next?

a.

Initiate rewarming of the patient.

b.

Complete a head-to-toe assessment.

c.

Obtain arterial blood gases (ABGs).

d.

Place the patient on high-flow oxygen.

ANS: D

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 patient is normothermic. The other actions also are appropriate, but the initial action should be to administer oxygen.

DIF: Cognitive Level: Application REF: 501 | 502

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

18. After the nurse has received change-of-shift report, which of these patients should be assessed first?

a.

A patient with pneumonia who has crackles in the right lung base

b.

A patient with chronic obstructive pulmonary disease (COPD) and pulmonary function testing (PFT) that indicates low forced vital capacity

c.

A patient with possible lung cancer who has just returned after bronchoscopy

d.

A patient with hemoptysis and a 16-mm induration with tuberculin skin testing

ANS: C

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

DIF: Cognitive Level: Application REF: 514

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Safe and Effective Care Environment

19. The nurse has just received arterial blood gas (ABG) results on four patients. Which result is most important to report rapidly to the health care provider?

a.

pH 7.34, PaO2 82 mm Hg, PaCO2 40 mm Hg, and O2 sat 97%

b.

pH 7.35, PaO2 85 mm Hg, PaCO2 45 mm Hg, and O2 sat 95%

c.

pH 7.46, PaO2 90 mm Hg, PaCO2 32 mm Hg, and O2 sat 98%

d.

pH 7.31, PaO2 91 mm Hg, PaCO2 50 mm Hg, and O2 sat 96%

ANS: D

These ABGs indicate uncompensated respiratory acidosis and should be reported to the health care provider. The other values are normal or close to normal.

DIF: Cognitive Level: Application REF: 501

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

20. The nurse obtains this information when assessing a patient with chronic obstructive pulmonary disease (COPD) who has been admitted with increasing dyspnea over the last 3 days. Which finding is most important to report to the health care provider?

a.

Respirations are 36 breaths/minute.

b.

Anterior-posterior chest ratio is 1:1.

c.

Lung expansion is decreased bilaterally.

d.

Hyperresonance to percussion is present.

ANS: A

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 patients with COPD.

DIF: Cognitive Level: Application REF: 507-509

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

21. When performing an assessment of the patients respiratory system, the nurse uses the following illustrated technique to evaluate

a.

bronchophony.

b.

chest expansion.

c.

accessory muscle use.

d.

diaphragmatic excursion.

ANS: B DIF: Cognitive Level: Comprehension

REF: 508 | video clips on Companion CD

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

MULTIPLE RESPONSE

1. Which nursing actions will be included when sending a patient for computed tomography (CT) of the chest with contrast (select all that apply)?

a.

Ask the patient about any claustrophobia.

b.

Question the patient about allergies to iodine.

c.

Avoid administration of bronchodilator drugs.

d.

Have the patient remove wedding bands or any other jewelry.

e.

Review the recent blood urea nitrogen (BUN) and creatinine levels.

ANS: B, E

Since the contrast dye is iodine-based and may cause dehydration and decreased renal blood flow, asking about iodine allergies and monitoring renal function before the CT scan is necessary. The other actions are not needed for CT of the chest, although they may be needed for other diagnostic tests, such as magnetic resonance imaging (MRI) or pulmonary function testing (PFT).

DIF: Cognitive Level: Analysis REF: 513-514

OBJ: Special Questions: Alternate Item Format

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

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