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Chapter 05: Assessing the Respiratory System
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. Which respiratory disorders may be genetically linked?
| 1) | Emphysema |
| 2) | Tuberculosis |
| 3) | Cor pulmonale |
| 4) | Pneumonia |
____ 2. Which is the best position to place the patient in to assess the lungs?
| 1) | Supine |
| 2) | Prone |
| 3) | Fowler’s |
| 4) | Side-lying |
____ 3. A respiratory rate of 20 for an adult patient is documented using which term?
| 1) | Eupnea |
| 2) | Dyspnea |
| 3) | Bradypnea |
| 4) | Tachypnea |
____ 4. Which definition best describes Kussmaul breathing, seen in diabetic ketoacidosis or lactic acidosis?
| 1) | Progressively increasing, rapid, deep respiration that peaks and then gradually decreases |
| 2) | Rapid and deep respirations |
| 3) | Irregular rate and depth that alternates with periods of apnea |
| 4) | Regular breathing pattern followed by brief periods of apnea |
____ 5. Pursed-lip breathing is most often seen in patients with which disease process?
| 1) | Asthma |
| 2) | Pneumonia |
| 3) | COPD |
| 4) | Cor pulmonale |
____ 6. The nurse notes clubbing of the nails during the physical assessment. Based on this data, which condition does the nurse suspect?
| 1) | Iron deficiency anemia |
| 2) | Hypoglycemia |
| 3) | Hyperthyroidism |
| 4) | Polycythemia |
____ 7. Which is the reason for assessing a patient’s chest excursion?
| 1) | Monitoring for complete or partial airway obstruction |
| 2) | Monitoring for pleural effusion |
| 3) | Monitoring for pneumothorax |
| 4) | All of the above |
____ 8. On auscultation of the patient’s lung fields, crackles that do not clear with coughing are heard bilaterally at the bases. Which conclusion by the nurse is the most appropriate based on these assessment findings?
| 1) | Collapsed alveoli popping open |
| 2) | Fluid in the lungs |
| 3) | Rales auscultated at the bases |
| 4) | All of the above |
____ 9. Upon palpation of the patient’s rib cage, the nurse notes a crackling sensation like crumpling cellophane. Which conclusion by the nurse is appropriate?
| 1) | Fluid leaking into the surrounding tissue |
| 2) | Air leaking into the surrounding tissue |
| 3) | Infection of the lung |
| 4) | Cancer in the lung |
____ 10. The nurse asks the patient to repeat saying the number “99” several times as the rib cage is lightly palpated. Which is the nurse assessing for using this technique?
| 1) | Fremitus |
| 2) | Egophony |
| 3) | Excursion |
| 4) | Crepitus |
____ 11. Which assessment finding could indicate that the patient has lung cancer?
| 1) | Clear sputum |
| 2) | Crackles upon auscultation |
| 3) | Eupnea |
| 4) | Fatigue |
____ 12. An adult patient is admitted to the hospital with an acute exacerbation of chronic obstructive pulmonary disease (COPD). During the health history the patient admits dyspnea on exertion (DOE), cough, weight gain, and swollen ankles. Which of these findings is most frequently associated with respiratory disorders?
| 1) | DOE |
| 2) | Cough |
| 3) | Weight gain |
| 4) | Swollen ankles |
____ 13. Upon inspection, the nurse notes that the patient has a barrel chest. What is the normal anteroposterior (AP)-to-lateral chest ratio?
| 1) | 1:1 |
| 2) | 1:2 |
| 3) | 1:3 |
| 4) | 1:4 |
____ 14. Inspection of the patient’s chest reveals a wide costal angle. Which costal angle is expected for a healthy adult?
| 1) | 45 degrees |
| 2) | 90 degrees |
| 3) | 160 degrees |
| 4) | 180 degrees |
____ 15. The nurse observes that the patient is using intercostal muscles for breathing. Adult males normally use which muscles for breathing?
| 1) | Sternocleidomastoid |
| 2) | Thoracic |
| 3) | Abdominal |
| 4) | Cervical |
____ 16. Considering the patient’s diagnosis of chronic obstructive pulmonary disease (COPD), the nurse assesses for signs and symptoms of hypoxia. What may alert the nurse to early signs and symptoms of hypoxia?
| 1) | Change in mental status |
| 2) | Cyanosis |
| 3) | Tachycardia |
| 4) | Clubbing |
____ 17. While palpating the patient’s chest, the nurse assesses the respiratory excursion. What is this technique used to assess?
| 1) | Chest movement |
| 2) | Breath sounds |
| 3) | Lung vibrations |
| 4) | Voice sounds |
____ 18. The nurse assesses a patient for tactile fremitus. Which statement best defines tactile fremitus?
| 1) | Palpable vibrations |
| 2) | Audible voice sounds |
| 3) | Audible breath sounds |
| 4) | Palpable chest movement |
____ 19. Percussion over healthy lung tissue normally elicits which sound?
| 1) | Tympany |
| 2) | Dullness |
| 3) | Resonance |
| 4) | Hyperresonance |
____ 20. The nurse is assessing a patient diagnosed with emphysema. Which does the nurse anticipate when percussing over the patient’s lungs?
| 1) | Tympany |
| 2) | Dullness |
| 3) | Resonance |
| 4) | Hyperresonance |
____ 21. The nurse is assessing an older adult patient who is admitted to the hospital with aspiration pneumonia of the right middle lobe. Which approaches will best facilitate assessment of the right middle lobe of the lung?
| 1) | Anterior and lateral |
| 2) | Posterior and lateral |
| 3) | Posterior and anterior |
| 4) | Superior and inferior |
____ 22. When assessing for cyanotic changes, central cyanosis may be distinguished from peripheral cyanosis. Which location does the nurse use to assess for central cyanosis?
| 1) | On the ear lobes |
| 2) | In the nailbeds |
| 3) | In the mucous membranes |
| 4) | On the fingers |
____ 23. The nurse detects crackles when auscultating a patient’s chest. Which statement accurately characterizes crackles?
| 1) | Crackles are more predominant on inspiration. |
| 2) | Crackles are unaffected by coughing. |
| 3) | Crackles are heard over the large airways. |
| 4) | Crackles occur on inspiration and expiration. |
____ 24. The nurse notes scattered rhonchi when auscultating the patient’s chest. How do rhonchi differ from crackles?
| 1) | Rhonchi are best heard in the periphery of the lungs. |
| 2) | Rhonchi are affected by coughing. |
| 3) | Rhonchi occur predominantly on inspiration. |
| 4) | Rhonchi have a rattle-like quality. |
____ 25. Because the patient has pneumonia, the nurse assesses for abnormal voice sounds. The patient has clearer transmission of spoken voice sounds. This is an example of which type of voice sound?
| 1) | Bronchophony |
| 2) | Whispered pectoriloquy |
| 3) | Egophony |
| 4) | Stridor |
____ 26. The nurse is assessing a patient diagnosed with consolidation pneumonia. Which type of breath sounds would the nurse expect to auscultate over the affected area?
| 1) | Rales |
| 2) | Tracheal |
| 3) | Vesicular |
| 4) | Bronchial |
____ 27. Which type of breath sound would the nurse expect to auscultate over most of the lung fields in a healthy patient?
| 1) | Bronchial |
| 2) | Tracheal |
| 3) | Vesicular |
| 4) | Bronchovesicular |
____ 28. The nurse is assessing a patient who is admitted with the diagnosis of pleuritis. Auscultation of the patient’s thorax reveals a pleural friction rub. How can the nurse differentiate this sound from other abnormal breath sounds?
| 1) | Rubs occur during inspiration and clear with coughing. |
| 2) | Rubs occur during expiration and produce a light popping sound. |
| 3) | Rubs occur during inspiration and may be heard anywhere. |
| 4) | Rubs occur during inspiration and expiration and are unaffected by coughing. |
____ 29. The patient develops a pleural effusion, so a chest tube is inserted. The nurse detects crepitus at the insertion site. Which conclusion by the nurse is most appropriate?
| 1) | Consolidation of the lung tissue |
| 2) | Pleural thickening |
| 3) | Air leakage into subcutaneous tissue |
| 4) | Obstructed airway |
____ 30. Which physical assessment technique would be used to determine the AP:lateral ratio?
| 1) | Inspection |
| 2) | Palpation |
| 3) | Percussion |
| 4) | Auscultation |
____ 31. Which physical assessment technique would be used to identify tactile fremitus?
| 1) | Inspection |
| 2) | Palpation |
| 3) | Percussion |
| 4) | Auscultation |
____ 32. Which physical assessment technique would be used to identify wheezing?
| 1) | Inspection |
| 2) | Palpation |
| 3) | Percussion |
| 4) | Auscultation |
____ 33. Which physical assessment technique would best determine chest excursion?
| 1) | Inspection |
| 2) | Palpation |
| 3) | Percussion |
| 4) | Auscultation |
____ 34. Which physical assessment technique would be used to identify egophony?
| 1) | Inspection |
| 2) | Palpation |
| 3) | Percussion |
| 4) | Auscultation |
____ 35. Which physical assessment technique would be used to identify dullness?
| 1) | Inspection |
| 2) | Palpation |
| 3) | Percussion |
| 4) | Auscultation |
____ 36. Which physical assessment technique would be used to identify rales?
| 1) | Inspection |
| 2) | Palpation |
| 3) | Percussion |
| 4) | Auscultation |
____ 37. Which physical assessment technique would be used to identify sternal retraction?
| 1) | Inspection |
| 2) | Palpation |
| 3) | Percussion |
| 4) | Auscultation |
____ 38. Which standard view is typically inappropriate when conducting a respiratory assessment?
| 1) | Anterior |
| 2) | Posterior |
| 3) | Lateral |
| 4) | Superior |
Chapter 05: Assessing the Respiratory System
Answer Section
MULTIPLE CHOICE
1.ANS:1
Chapter number and title: 5, Assessing the Respiratory System
Chapter learning objective: N/A
Chapter page reference: 153
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive level: Knowledge [Remembering]
Concept: Diversity, Assessment
Difficulty: Easy
| Feedback | |
| 1 | Alpha antitrypsin deficiency may lead to genetically linked emphysema. |
| 2 | Tuberculosis is caused by the Mycobacterium. |
| 3 | Cor pulmonale is acute right-sided heart failure. |
| 4 | Pneumonia may be viral or bacterial in origin. |
PTS: 1 CON: Diversity | Assessment
2.ANS:3
Chapter number and title: 5, Assessing the Respiratory System
Chapter learning objective: N/A
Chapter page reference: 164
Integrated Processes: Nursing Process: Assessment
Client Need: Health Promotion and Maintenance
Cognitive level: Comprehension [Understanding]
Concept: Assessment, Oxygenation
Difficulty: Easy
| Feedback | |
| 1 | A supine position is not appropriate for a respiratory assessment. |
| 2 | A prone position is not appropriate for a respiratory assessment. |
| 3 | The best position for the exam is with the patient sitting. |
| 4 | A side-lying position is not appropriate for a respiratory assessment. |
PTS: 1 CON: Assessment | Oxygenation
3.ANS:1
Chapter number and title: 5, Assessing the Respiratory System
Chapter learning objective: N/A
Chapter page reference: 164
Integrated Processes: Communication and Documentation
Client Need: Health Promotion and Maintenance
Cognitive level: Application [Applying]
Concept: Oxygenation, Communication, Assessment
Difficulty: Easy
| Feedback | |
| 1 | Eupnea refers to normal rate, depth, and rhythm of respirations. Normal adult rate is 14 to 20 breaths/min. |
| 2 | Dyspnea is difficulty breathing. |
| 3 | Bradypnea is a respiratory rate below normal. |
| 4 | Tachypnea is an increase in rate above normal. |
PTS:1CON:Oxygenation | Communication | Assessment
4.ANS:2
Chapter number and title: 5, Assessing the Respiratory System
Chapter learning objective: N/A
Chapter page reference: 165
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Oxygenation, Assessment
Difficulty: Easy
| Feedback | |
| 1 | This is not an accurate description of Kussmaul respiration. |
| 2 | Kussmaul respiration is characterized by rapid, deep respiration associated with metabolic acidosis. |
| 3 | This is not an accurate description of Kussmaul respiration. |
| 4 | This is not an accurate description of Kussmaul respiration. |
PTS: 1 CON: Oxygenation | Assessment
5.ANS:3
Chapter number and title: 5, Assessing the Respiratory System
Chapter learning objective: N/A
Chapter page reference: 159
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Oxygenation, Assessment
Difficulty: Easy
| Feedback | |
| 1 | Pursed-lip breathing is not most often seen in patients diagnosed with asthma. |
| 2 | Pursed-lip breathing is not most often seen in patients diagnosed with pneumonia. |
| 3 | Pursed-lip breathing, or physiological positive end-expiratory pressure, is a compensatory mechanism used by people with COPD to prolong expiration, help expel trapped air, and keep alveoli open longer for maximum oxygenation of pulmonary blood. |
| 4 | Pursed-lip breathing is not most often seen in patients diagnosed with cor pulmonale. |
PTS: 1 CON: Oxygenation | Assessment
6.ANS:4
Chapter number and title: 5, Assessing the Respiratory System
Chapter learning objective: N/A
Chapter page reference: 158
Integrated Processes: Nursing Process: Evaluation
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive level: Analysis [Analyzing]
Concept: Oxygenation
Difficulty: Difficult
| Feedback | |
| 1 | Iron deficiency anemia is caused by a decrease in red blood cells. This condition is not associated with clubbing. |
| 2 | Hypoglycemia is a decrease in serum blood glucose. This condition is not associated with clubbing. |
| 3 | Hyperthyroidism is not a condition that is associated with clubbing. |
| 4 | The increase in red blood cells (RBCs; polycythemia) results in thick, sluggish blood flow that plugs the capillaries of the nail folds, causing the tissue to become swollen and spongy, resulting in clubbing. |
PTS: 1 CON: Oxygenation
7.ANS:4
Chapter number and title: 5, Assessing the Respiratory System
Chapter learning objective: N/A
Chapter page reference: 167
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Oxygenation
Difficulty: Easy
| Feedback | |
| 1 | The nurse assesses the patient’s chest excursion to monitor for complete or partial airway obstruction. |
| 2 | The nurse assesses the patient’s chest excursion to monitor for pleural effusion. |
| 3 | The nurse assesses the patient’s chest excursion to monitor for pneumothorax. |
| 4 | Asymmetrical excursion is associated with thoracotomy (removal of lung or lobes), complete or partial airway obstruction, pleural effusion, and pneumothorax. |
PTS: 1 CON: Oxygenation
8.ANS:4
Chapter number and title: 5, Assessing the Respiratory System
Chapter learning objective: N/A
Chapter page reference: 170
Integrated Processes: Nursing Process: Evaluation
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive level: Evaluation [Evaluating]
Concept: Oxygenation, Assessment
Difficulty: Difficult
| Feedback | |
| 1 | Crackles heard at the base of the lungs indicate collapsed alveoli popping open. |
| 2 | Crackles heard at the base of the lungs result from the air bubbling through moisture in the alveoli. |
| 3 | Another term for crackles is rales. |
| 4 | Rales or crackles are discontinuous sounds resulting from air bubbling through moisture in the alveoli or from collapsed alveoli popping open. |
PTS: 1 CON: Oxygenation | Assessment
9.ANS:2
Chapter number and title: 5, Assessing the Respiratory System
Chapter learning objective: N/A
Chapter page reference: 167
Integrated Processes: Nursing Process: Evaluation
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive level: Analysis [Analyzing]
Concept: Oxygenation, Assessment
Difficulty: Difficult
| Feedback | |
| 1 | Fluid leaking in to the surrounding tissue will not manifest as crepitus. |
| 2 | Crepitus feels crackly, like crumpling cellophane, and indicates air leaking into the tissue instead of the lungs. |
| 3 | Infection of the lung does not manifest as crepitus. |
| 4 | Cancer of the lung does not manifest as crepitus. |
PTS: 1 CON: Oxygenation | Assessment
10.ANS:1
Chapter number and title: 5, Assessing the Respiratory System
Chapter learning objective: N/A
Chapter page reference: 167
Integrated Processes: Nursing Process: Assessment
Client Need: Health Promotion and Maintenance
Cognitive level: Application [Applying]
Concept: Assessment, Oxygenation
Difficulty: Moderate
| Feedback | |
| 1 | As the patient says “99” repeatedly, the examiner’s hands move from apex to base to assess the level where fremitus is palpable. |
| 2 | Egophony is an abnormal voice sound. |
| 3 | Excursion is inspected, not palpated. |
| 4 | Crepitus is not assessed using this technique. |
PTS: 1 CON: Assessment | Oxygenation
11.ANS:4
Chapter number and title: 5, Assessing the Respiratory System
Chapter learning objective: N/A
Chapter page reference: 157
Integrated Processes: Nursing Process: Evaluation
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Cellular Regulation, Oxygenation
Difficulty: Easy
| Feedback | |
| 1 | Clear sputum is not an assessment finding associated with lung cancer. |
| 2 | Crackles upon auscultation could indicate infection but are not associated with lung cancer. |
| 3 | Eupnea is the term used to describe normal, regular breathing. |
| 4 | Fatigue is a symptom that is often associated with lung cancer. |
PTS: 1 CON: Cellular Regulation | Oxygenation
12.ANS:2
Chapter number and title: 5, Assessing the Respiratory System
Chapter learning objective: N/A
Chapter page reference: 170
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive level: Synthesis [Creating]
Concept: Oxygenation
Difficulty: Easy
| Feedback | |
| 1 | DOE is not a finding that is most frequently associated with respiratory disorders. |
| 2 | Coughing is one of the most common respiratory complaints. |
| 3 | Weight gain is not a finding that is most frequently associated with respiratory disorders. |
| 4 | Edema is not a finding that is most frequently associated with respiratory disorders. |
PTS: 1 CON: Oxygenation
13.ANS:2
Chapter number and title: 5, Assessing the Respiratory System
Chapter learning objective: N/A
Chapter page reference: 165
Integrated Processes: Nursing Process: Assessment
Client Need: Health Promotion and Maintenance
Cognitive level: Knowledge [Remembering]
Concept: Oxygenation, Assessment
Difficulty: Easy
| Feedback | |
| 1 | 1:1 is a normal AP-to-lateral ratio for an infant. |
| 2 | A normal adult chest has an AP-to-lateral ratio of approximately 1:2. |
| 3 | 1:3 is not a normal AP-to-lateral ratio. |
| 4 | 1:4 is not a normal AP-to-lateral ratio. |
PTS: 1 CON: Oxygenation | Assessment
14.ANS:2
Chapter number and title: 5, Assessing the Respiratory System
Chapter learning objective: N/A
Chapter page reference: 165
Integrated Processes: Nursing Process: Assessment
Client Need: Health Promotion and Maintenance
Cognitive level: Comprehension [Understanding]
Concept: Oxygenation, Assessment
Difficulty: Easy
| Feedback | |
| 1 | 45 degrees is not the expected costal angle. |
| 2 | The normal costal angle is approximately 90 degrees. |
| 3 | A costal angle greater than 90 degrees may indicate chronic obstructive pulmonary disease (COPD). |
| 4 | A costal angle greater than 90 degrees may indicate chronic obstructive pulmonary disease (COPD). |
PTS: 1 CON: Oxygenation | Assessment
15.ANS:3
Chapter number and title: 5, Assessing the Respiratory System
Chapter learning objective: N/A
Chapter page reference: 166
Integrated Processes: Nursing Process: Assessment
Client Need: Health Promotion and Maintenance
Cognitive level: Comprehension [Understanding]
Concept: Oxygenation
Difficulty: Easy
| Feedback | |
| 1 | Use of the accessory muscles, such as the neck (sternocleidomastoid) muscles, is often a sign of respiratory distress. |
| 2 | The intercostal muscles arise in the upper thoracic segments. |
| 3 | Men are normally more abdominal breathers, whereas women are more chest breathers. |
| 4 | Use of the accessory muscles, such as the neck (cervical) muscles, is often a sign of respiratory distress. |
PTS: 1 CON: Oxygenation
16.ANS:1
Chapter number and title: 5, Assessing the Respiratory System
Chapter learning objective: N/A
Chapter page reference: 157
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Oxygenation, Assessment
Difficulty: Moderate
| Feedback | |
| 1 | A change in mental status is an early sign of hypoxia. As the person becomes hypoxic, tachycardia develops. |
| 2 | Cyanosis is a late sign of hypoxia. |
| 3 | Tachycardia is not a symptom of hypoxia. |
| 4 | Clubbing results from chronic hypoxia. |
PTS: 1 CON: Oxygenation | Assessment
17.ANS:1
Chapter number and title: 5, Assessing the Respiratory System
Chapter learning objective: N/A
Chapter page reference: 168
Integrated Processes: Nursing Process: Assessment
Client Need: Health Promotion and Maintenance
Cognitive level: Comprehension [Understanding]
Concept: Oxygenation, Assessment
Difficulty: Easy
| Feedback | |
| 1 | Chest excursion refers to the chest’s expandability. |
| 2 | Breath sounds are assessed by auscultation. |
| 3 | Lung vibrations are assessed by percussion. |
| 4 | Voice sounds are assessed by auscultation. |
PTS: 1 CON: Oxygenation | Assessment
18.ANS:1
Chapter number and title: 5, Assessing the Respiratory System
Chapter learning objective: N/A
Chapter page reference: 167
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Oxygenation, Assessment
Difficulty: Easy
| Feedback | |
| 1 | Tactile or vocal fremitus is the palpable vibration the examiner feels when the patient speaks. |
| 2 | Audible voice sounds and breath sounds are assessed through auscultation. |
| 3 | Audible voice sounds and breath sounds are assessed through auscultation. |
| 4 | Excursion assesses chest movement. |
PTS: 1 CON: Oxygenation | Assessment
19.ANS:3
Chapter number and title: 5, Assessing the Respiratory System
Chapter learning objective: N/A
Chapter page reference: 168
Integrated Processes: Nursing Process: Assessment
Client Need: Health Promotion and Maintenance
Cognitive level: Comprehension [Understanding]
Concept: Assessment
Difficulty: Easy
| Feedback | |
| 1 | Tympany is normally percussed over the abdomen. |
| 2 | Dullness is normally percussed over organs. |
| 3 | The normal percussion noted over adult lung fields is called resonance. |
| 4 | Hyperresonance is noted with air trapping of emphysema. |
PTS: 1 CON: Assessment
20.ANS:4
Chapter number and title: 5, Assessing the Respiratory System
Chapter learning objective: N/A
Chapter page reference: 168
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Oxygenation, Assessment
Difficulty: Moderate
| Feedback | |
| 1 | Tympany is percussed over the abdomen. |
| 2 | Dullness is normally percussed over organs or masses. |
| 3 | Resonance is noted when percussing over healthy lung tissue. |
| 4 | Hyperresonance is noted with air trapping of emphysema. |
PTS: 1 CON: Oxygenation | Assessment
21.ANS:1
Chapter number and title: 5, Assessing the Respiratory System
Chapter learning objective: N/A
Chapter page reference: 163
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Oxygenation, Assessment
Difficulty: Moderate
| Feedback | |
| 1 | Because of the anatomical position of the right middle lobe, the anterior and lateral approaches are best for assessment. |
| 2 | The right middle lobe is not readily accessible using the posterior approach. |
| 3 | The right middle lobe is not readily accessible using the posterior approach. |
| 4 | Using the superior and inferior approach is not appropriate. |
PTS: 1 CON: Oxygenation | Assessment
22.ANS:3
Chapter number and title: 5, Assessing the Respiratory System
Chapter learning objective: N/A
Chapter page reference: 158
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Oxygenation, Assessment
Difficulty: Moderate
| Feedback | |
| 1 | Peripheral cyanosis is seen on the ear lobes, nailbeds, and fingers. |
| 2 | Peripheral cyanosis is seen on the ear lobes, nailbeds, and fingers. |
| 3 | With central cyanosis, there is a dusky or blue buccal mucosa and tongue when PO2 is less than 50. |
| 4 | Peripheral cyanosis is seen on the ear lobes, nailbeds, and fingers. |
PTS: 1 CON: Oxygenation | Assessment
23.ANS:1
Chapter number and title: 5, Assessing the Respiratory System
Chapter learning objective: N/A
Chapter page reference: 171
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Oxygenation, Assessment
Difficulty: Easy
| Feedback | |
| 1 | Crackles tend to occur at the end of inspiration, in the terminal bronchioles and alveoli. |
| 2 | Depending on the cause, crackles may be affected by coughing. Loose exudate rales may clear with coughing. |
| 3 | Crackles are heard over small airways, not large airways. |
| 4 | Crackles are typically heard during inspiration. |
PTS: 1 CON: Oxygenation | Assessment
24.ANS:4
Chapter number and title: 5, Assessing the Respiratory System
Chapter learning objective: N/A
Chapter page reference: 171
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive level: Analysis [Analyzing]
Concept: Oxygenation
Difficulty: Difficult
| Feedback | |
| 1 | Crackles are best heard in the periphery of the lungs; rhonchi are best heard in larger airways. |
| 2 | Crackles are affected by coughing; rhonchi are unaffected by coughing. |
| 3 | Crackles occur predominantly on inspiration; rhonchi occur predominantly on expiration. |
| 4 | Crackles are discontinuous, popping sounds; rhonchi have a snoring or rattle-like quality due to air being forced through a narrowed airway. |
PTS: 1 CON: Oxygenation
25.ANS:1
Chapter number and title: 5, Assessing the Respiratory System
Chapter learning objective: N/A
Chapter page reference: 171
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Oxygenation
Difficulty: Easy
| Feedback | |
| 1 | Bronchophony is the abnormal clarity of the spoken word as heard through the stethoscope. |
| 2 | Whispered pectoriloquy is clearer transmission of whispered voice sounds. |
| 3 | Egophony is an “ee” to an “aa” change. |
| 4 | Stridor is an inspiratory sign of upper airway obstruction. |
PTS: 1 CON: Oxygenation
26.ANS:4
Chapter number and title: 5, Assessing the Respiratory System
Chapter learning objective: N/A
Chapter page reference: 170
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Oxygenation, Assessment
Difficulty: Moderate
| Feedback | |
| 1 | Rales are an adventitious sound superimposed over normal breath sounds. |
| 2 | Tracheal sounds are heard when auscultating over the trachea. |
| 3 | Vesicular sounds are normally heard in most of the lung fields. |
| 4 | Bronchial sounds are heard outside of their normal locations, as with fluid or consolidated tissue such as in pneumonia. |
PTS: 1 CON: Oxygenation | Assessment
27.ANS:3
Chapter number and title: 5, Assessing the Respiratory System
Chapter learning objective: N/A
Chapter page reference: 170
Integrated Processes: Nursing Process: Assessment
Client Need: Health Promotion and Maintenance
Cognitive level: Comprehension [Understanding]
Concept: Oxygenation, Assessment
Difficulty: Easy
| Feedback | |
| 1 | Bronchial sounds are normally heard in anterior neck and nape of neck posteriorly. |
| 2 | Tracheal sounds are normally heard over the trachea. |
| 3 | Vesicular breath sounds are soft and low pitched, with a long inspiratory phase and a short expiratory phase. They are heard over most lung fields. |
| 4 | Bronchovesicular sounds are normally heard over the mainstem bronchi. |
PTS: 1 CON: Oxygenation | Assessment
28.ANS:4
Chapter number and title: 5, Assessing the Respiratory System
Chapter learning objective: N/A
Chapter page reference: 171
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive level: Analysis [Analyzing]
Concept: Oxygenation, Assessment
Difficulty: Moderate
| Feedback | |
| 1 | Although the rub can occur on inspiration, it will not be affected by coughing. |
| 2 | Although the rub can occur on expiration, it will not produce a light popping sound. |
| 3 | Although the rub can occur during inspiration, the sound will not be heard anywhere. |
| 4 | The rub may occur during both inspiration and expiration, but because it is not in the lung, it will never be affected by coughing. |
PTS: 1 CON: Oxygenation | Assessment
29.ANS:3
Chapter number and title: 5, Assessing the Respiratory System
Chapter learning objective: N/A
Chapter page reference: 167
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive level: Analysis [Analyzing]
Concept: Oxygenation
Difficulty: Moderate
| Feedback | |
| 1 | Crepitus is not the result of consolidation of the lung tissue. |
| 2 | Crepitus is not the result of pleural thickening. |
| 3 | Crepitus (subcutaneous emphysema) results from air leaking into subcutaneous tissue. |
| 4 | Crepitus is not the result of an obstructed airway. |
PTS: 1 CON: Oxygenation
30.ANS:1
Chapter number and title: 5, Assessing the Respiratory System
Chapter learning objective: N/A
Chapter page reference: 165
Integrated Processes: Nursing Process: Assessment
Client Need: Health Promotion and Maintenance
Cognitive level: Knowledge (Remembering)
Concept: Assessment
Difficulty: Easy
| Feedback | |
| 1 | Inspect the chest for size, shape, symmetry, and excursion. |
| 2 | The AP:lateral ratio is not determined by palpation. |
| 3 | The AP:lateral ratio is not determined by percussion. |
| 4 | The AP:lateral ratio is not determined by auscultation. |
PTS: 1 CON: Assessment
31.ANS:2
Chapter number and title: 5, Assessing the Respiratory System
Chapter learning objective: N/A
Chapter page reference: 167
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive level: Knowledge [Remembering]
Concept: Assessment, Oxygenation
Difficulty: Easy
| Feedback | |
| 1 | Inspection is not used to identify tactile fremitus. |
| 2 | Palpation is useful in assessing for tracheal position, tenderness, crepitus, chest excursion, and tactile fremitus. |
| 3 | Percussion is not used to identify tactile fremitus. |
| 4 | Auscultation is not used to identify tactile fremitus. |
PTS: 1 CON: Assessment | Oxygenation
32.ANS:4
Chapter number and title: 5, Assessing the Respiratory System
Chapter learning objective: N/A
Chapter page reference: 171
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive level: Knowledge [Remembering]
Concept: Assessment, Oxygenation
Difficulty: Easy
| Feedback | |
| 1 | Wheezing is not assessed by inspection. |
| 2 | Wheezing is not assessed by palpation. |
| 3 | Wheezing is not assessed by percussion. |
| 4 | Wheezing is the sound of narrowed or reactive airways from asthma or obstruction. Auscultation is best for assessing wheezes. |
PTS: 1 CON: Assessment | Oxygenation
33.ANS:2
Chapter number and title: 5, Assessing the Respiratory System
Chapter learning objective: N/A
Chapter page reference: 167
Integrated Processes: Nursing Process: Assessment
Client Need: Health Promotion and Maintenance
Cognitive level: Knowledge [Remembering]
Concept: Assessment, Oxygenation
Difficulty: Easy
| Feedback | |
| 1 | Inspect the chest for size, shape, symmetry, and excursion. |
| 2 | Palpation is best for assessing the equal expansion of the chest. |
| 3 | Percussion is not used to assess for chest excursion. |
| 4 | Auscultation is used to assess breath sounds but not chest excursion. |
PTS: 1 CON: Assessment | Oxygenation
34.ANS:4
Chapter number and title: 5, Assessing the Respiratory System
Chapter learning objective: N/A
Chapter page reference: 171
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive level: Knowledge [Remembering]
Concept: Assessment, Oxygenation
Difficulty: Easy
| Feedback | |
| 1 | Inspection is not used to assess for egophony. |
| 2 | Palpation is not used to assess for egophony. |
| 3 | Percussion is not used to assess for egophony. |
| 4 | Abnormal vocal sounds include bronchophony, egophony, and whispered pectoriloquy and are assessed with auscultation. |
PTS: 1 CON: Assessment | Oxygenation
35.ANS:3
Chapter number and title: 5, Assessing the Respiratory System
Chapter learning objective: N/A
Chapter page reference: 168
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive level: Knowledge [Remembering]
Concept: Assessment, Oxygenation
Difficulty: Easy
| Feedback | |
| 1 | Inspection is not the assessment technique used to identify dullness. |
| 2 | Palpation is not the assessment technique used to identify dullness. |
| 3 | Percuss for resonance over the lung tissue to dullness over the diaphragm. |
| 4 | Auscultation is not the assessment technique used to identify dullness. |
PTS: 1 CON: Assessment | Oxygenation
36.ANS:4
Chapter number and title: 5, Assessing the Respiratory System
Chapter learning objective: N/A
Chapter page reference: 170
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive level: Knowledge [Remembering]
Concept: Assessment, Oxygenation
Difficulty: Easy
| Feedback | |
| 1 | Inspection is not used to identify rales. |
| 2 | Palpation is not used to identify rales. |
| 3 | Percussion is not used to identify rales. |
| 4 | Adventitious breath sounds are additional sounds superimposed over normal breath sounds; they include crackles or rales, and they are assessed with auscultation. |
PTS: 1 CON: Assessment | Oxygenation
37.ANS:1
Chapter number and title: 5, Assessing the Respiratory System
Chapter learning objective: N/A
Chapter page reference: 166
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive level: Knowledge [Remembering]
Concept: Assessment, Oxygenation
Difficulty: Easy
| Feedback | |
| 1 | Sternal retractions are noted during inspiration and are assessed by inspection. |
| 2 | Palpation is not used to identify retractions. |
| 3 | Percussion is not used to identify retractions. |
| 4 | Auscultation is not used to identify retractions. |
PTS: 1 CON: Assessment | Oxygenation
38.ANS:4
Chapter number and title: 5, Assessing the Respiratory System
Chapter learning objective: N/A
Chapter page reference: 164
Integrated Processes: Nursing Process: Assessment
Client Need: Health Promotion and Maintenance
Cognitive level: Application [Applying]
Concept: Assessment, Oxygenation
Difficulty: Moderate
| Feedback | |
| 1 | A respiratory assessment is often approached from an anterior view. |
| 2 | A respiratory assessment is often approached from a posterior view. |
| 3 | A respiratory assessment is often approached from a lateral view. |
| 4 | A respiratory assessment is not approached from a superior view. |
PTS: 1 CON: Assessment | Oxygenation
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