RESPIRATORY ASSESSMENT TEST BANK
EXAM QUESTIONS AND ANSWERS |
LATEST UPDATED .
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. - Correct Answer -d. Perform a respiratory system assessment and ask specific
questions about this episode of respiratory distress.
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.
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
1
, d. Sitting upright with the arms supported on an over bed table - Correct Answer -d. Sitting upright
with the arms supported on an over bed table.
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.
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. - Correct Answer -b. Kussmaul respirations
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.
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.
2
EXAM QUESTIONS AND ANSWERS |
LATEST UPDATED .
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. - Correct Answer -d. Perform a respiratory system assessment and ask specific
questions about this episode of respiratory distress.
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.
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
1
, d. Sitting upright with the arms supported on an over bed table - Correct Answer -d. Sitting upright
with the arms supported on an over bed table.
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.
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. - Correct Answer -b. Kussmaul respirations
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.
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.
2
