Chapter 14: Pulmonary Clinical Assessment and Diagnostic Procedures

Chapter 14: Pulmonary Clinical Assessment and Diagnostic Procedures

Complete Chapter Questions With Answers

Sample Questions Are Posted Below

1. Why would the nurse perform an inspection of the oral cavity during a complete pulmonary assessment?

ANS:  A

Severe hypoxia will be manifested by central cyanosis, which is evident in the oral and circumoral areas. Although dehydration and nutritional status can both be partially assessed by oral cavity inspection; this information is not as vital as determining hypoxia. Dyspnea means difficulty breathing.

2. Which of the following lung sounds would be most likely heard in a client experiencing an asthma attack?

ANS:  D

Wheezes are high-pitched, squeaking, whistling sounds produced by airflow through narrowed small airways. They are heard mainly on expiration but may also be heard throughout the ventilatory cycle. Depending on their severity, wheezes can be further classified as mild, moderate, or severe. Rales are crackling sounds produced by fluid in the small airways or alveoli or by the snapping open of collapsed airways during inspiration. A pleural friction rub is a dry, coarse sound produced by irritated pleural surfaces rubbing together and is caused by inflammation of the pleura.

3. Which of the following describes the major difference between tachypnea and hyperventilation?

ANS:  D

Tachypnea is manifested by an increase in the rate and decrease in the depth of ventilation. Hyperventilation is manifested by an increase in both the rate and depth of ventilation.

4. A patient presents with chest trauma from an MVA. Upon assessment, the nurse documents that the patient is complaining of dyspnea, shortness of breath, tachypnea, and tracheal deviation to the right. In addition, the client’s tongue is blue-gray. Based on the following data, what the nurse would expect to find?

ANS:  C

The clinical picture described is most consistent with left pneumothorax. This would cause the trachea to deviate to the right, away from the increasing pressure of the left. A pneumothorax this severe would completely collapse the right lung, thus causing absent breath sounds in that lung.

5. On assessment of a client, you note fremitus over the trachea but not in the lung periphery. You know that this most likely represents

ANS:  C

Fremitus is described as normal, decreased, or increased. With normal fremitus, vibrations can be felt over the trachea but are barely palpable over the periphery. With decreased fremitus, there is interference with the transmission of vibrations. Examples of disorders that decrease fremitus include pleural effusion, pneumothorax, bronchial obstruction, pleural thickening, and emphysema.