Chapter 25: Assessment of Respiratory System

Chapter 25: Assessment of Respiratory System

Complete Chapter Questions With Answers

Sample Questions Are Posted Below

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?

ANS:  B

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. Brief questioning and a focused physical assessment should be done rapidly to help determine the cause of the distress and suggest treatment. Checking for allergies is important, but it is not appropriate to complete the entire admission database at this time. The initial respiratory assessment must be completed before any diagnostic tests or interventions can be ordered.

DIF:    Cognitive Level: Apply (application)           REF:               459

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

2. The nurse prepares a patient with a left-sided pleural effusion for a thoracentesis. How should the nurse position the patient?

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: Apply (application)           REF:               471

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

3. A diabetic patient’s arterial blood gas (ABG) results are pH 7.28; PaCO₂ 34 mm Hg; PaO₂ 85 mm Hg; HCO₃^– 18 mEq/L. The nurse would expect which finding?

ANS:  B

Kussmaul (deep and rapid) respirations are a compensatory mechanism for metabolic acidosis. The low pH and low bicarbonate result indicate metabolic acidosis. Intercostal retractions, a low oxygen saturation rate, and a decrease in venous O₂ pressure would not be caused by acidosis.

DIF:    Cognitive Level: Apply (application)           REF:               467

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

4. On auscultation of a patient’s lungs, the nurse hears low-pitched, bubbling sounds during inhalation in the lower third of both lungs. How should the nurse document this finding?

ANS:  A

Crackles are low-pitched, bubbling sounds usually heard on inspiration. Wheezes are high-pitched sounds. They can be heard during the expiratory or inspiratory phase of the respiratory cycle. The lower third of both lungs are the bases, not apices. Pleural friction rubs are grating sounds that are usually heard during both inspiration and expiration.

DIF:    Cognitive Level: Apply (application)           REF:               468

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

5. The nurse palpates the posterior chest while the patient says “99” and notes absent fremitus. Which action should the nurse take next?

ANS:  D

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.” After noting absent fremitus, the nurse should then auscultate the lungs to assess for the presence or absence of breath sounds. Absent fremitus may be noted with pneumothorax or atelectasis. The vibration is increased in conditions such as pneumonia, lung tumors, thick bronchial secretions, and pleural effusion. Turning, coughing, and deep breathing is an appropriate intervention for atelectasis, but the nurse needs to first assess breath sounds. Fremitus is decreased if the hand is farther from the lung or the lung is hyperinflated (barrel chest). The anterior of the chest is more difficult to palpate for fremitus because of the presence of large muscles and breast tissue.

DIF:    Cognitive Level: Apply (application)           REF:               464

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