C HAPTER 17: P ULMONARY C LINICAL
A SSESSMENT
Urden: Critical Care Nursing, 9th Edition
MULTIPLE CHOICE
1. A patient is admitted with acute lung failure secondary to chronic
obstructive pulmonary disease (COPD). Upon inspection of the patient,
the nurse observes that the patient’s fingers appear discolored. What does
this finding indicate the presence of ?
a. Clubbing
b. Central cyanosis
c. Peripheral cyanosis
d. Chronic tuberculosis
ANS: C
Discoloration of the fingers is an indication of peripheral cyanosis.
Central cyanosis occurs when the unsaturated hemoglobin of arterial
blood exceeds 5 g/dL and is considered a life-threatening situation.
Clubbing refers to an abnormalit y of the fingers caused by chronicall y
low blood levels of oxygen often related to a heart or lung disease.
PTS: 1 DIF: Cognitive Level: Understanding REF: p.
431 OBJ: Nursing Process Step: Assessment TOP:
Pulmonary MSC: NC LEX: Physiologic Integrit y
,2. A patient is admitted with acute lung failure secondary to emphysema.
Percussion of the lung fields will predictabl y exhibit which tone?
a. Resonance
b. Hyperresonance
c. Tympany
d. Dullness
ANS: B
The percussion tone of hyperresonance is heard with emphysema
related to overinflation of the lung. Resonance can be found in normal
lungs or with the diagnosis of bronchitis. Tympany occurs with the
diagnosis of large pneumothorax and emphysematous blebs. Dull ness
occurs with the diagnosis of atelectasis, pleural effusion, pulmonary
edema, pneumonia, and a lung mass.
PTS: 1 DIF: Cognitive Level: Understanding REF: p.
436 | Table 17 -1 OBJ: Nursing Process Step: Assessment
TOP: Pulmonary MSC: NC LEX: Physiologic Integrit y
3. A patient is admitted with acute respiratory failure secondary to
pneumonia. Upon auscultation, the nurse hears creaking, leathery, coarse
breath sounds in the lower anterolateral chest area during inspiration and
expiration. This finding is indicative of what condition?
a. Emphysema
b. Atelectasis
c. Pulmonary fibrosis
d. Pleural effusion
ANS: D
, A pleural friction rub is the result of irritated pleural surfaces rubbing
together and is characterized by a leathery, dry, loud, coarse sound. A
pleural friction rub is seen with pleural effusions or pleurisy and is not
indicative of emphysema, atelectasis, or pulmonary fibrosis.
PTS: 1 DIF: Cognitive Level: Appl ying REF: p. 438 |
Table 17-2 OBJ: Nursing Process Step: Assessment TOP:
Pulmonary MSC: NC LEX: Physiologic Integrit y
4. A patient is admitted with an exacerbation of chronic obstructive
pulmonary disease (COPD). The nurse notes that the patient has difficult y
getting breath out. Which phrase best describes the patient’s breathing
pattern?
a. Deep sighing breaths without pauses
b. Rapid, shallow breaths
c. Normal breathing pattern interspersed with forced expirations
d. Irregular breathing pattern with both deep and shallow breaths
ANS: C
Difficult y getting breath out is indicative of air trapping. Air trap ping
is described as a normal breathing pattern interspersed with forced
expirations. As the patient breathes, air becomes trapped in the lungs,
and ventilations become progressivel y shallower until the patient
activel y and forcefully exhales.
PTS: 1 DIF: Cognitive Level: Appl ying REF: p. 433
OBJ: Nursing Process Step: Assessment TOP:
Pulmonary MSC: NC LEX: Physiologic Integrit y
A SSESSMENT
Urden: Critical Care Nursing, 9th Edition
MULTIPLE CHOICE
1. A patient is admitted with acute lung failure secondary to chronic
obstructive pulmonary disease (COPD). Upon inspection of the patient,
the nurse observes that the patient’s fingers appear discolored. What does
this finding indicate the presence of ?
a. Clubbing
b. Central cyanosis
c. Peripheral cyanosis
d. Chronic tuberculosis
ANS: C
Discoloration of the fingers is an indication of peripheral cyanosis.
Central cyanosis occurs when the unsaturated hemoglobin of arterial
blood exceeds 5 g/dL and is considered a life-threatening situation.
Clubbing refers to an abnormalit y of the fingers caused by chronicall y
low blood levels of oxygen often related to a heart or lung disease.
PTS: 1 DIF: Cognitive Level: Understanding REF: p.
431 OBJ: Nursing Process Step: Assessment TOP:
Pulmonary MSC: NC LEX: Physiologic Integrit y
,2. A patient is admitted with acute lung failure secondary to emphysema.
Percussion of the lung fields will predictabl y exhibit which tone?
a. Resonance
b. Hyperresonance
c. Tympany
d. Dullness
ANS: B
The percussion tone of hyperresonance is heard with emphysema
related to overinflation of the lung. Resonance can be found in normal
lungs or with the diagnosis of bronchitis. Tympany occurs with the
diagnosis of large pneumothorax and emphysematous blebs. Dull ness
occurs with the diagnosis of atelectasis, pleural effusion, pulmonary
edema, pneumonia, and a lung mass.
PTS: 1 DIF: Cognitive Level: Understanding REF: p.
436 | Table 17 -1 OBJ: Nursing Process Step: Assessment
TOP: Pulmonary MSC: NC LEX: Physiologic Integrit y
3. A patient is admitted with acute respiratory failure secondary to
pneumonia. Upon auscultation, the nurse hears creaking, leathery, coarse
breath sounds in the lower anterolateral chest area during inspiration and
expiration. This finding is indicative of what condition?
a. Emphysema
b. Atelectasis
c. Pulmonary fibrosis
d. Pleural effusion
ANS: D
, A pleural friction rub is the result of irritated pleural surfaces rubbing
together and is characterized by a leathery, dry, loud, coarse sound. A
pleural friction rub is seen with pleural effusions or pleurisy and is not
indicative of emphysema, atelectasis, or pulmonary fibrosis.
PTS: 1 DIF: Cognitive Level: Appl ying REF: p. 438 |
Table 17-2 OBJ: Nursing Process Step: Assessment TOP:
Pulmonary MSC: NC LEX: Physiologic Integrit y
4. A patient is admitted with an exacerbation of chronic obstructive
pulmonary disease (COPD). The nurse notes that the patient has difficult y
getting breath out. Which phrase best describes the patient’s breathing
pattern?
a. Deep sighing breaths without pauses
b. Rapid, shallow breaths
c. Normal breathing pattern interspersed with forced expirations
d. Irregular breathing pattern with both deep and shallow breaths
ANS: C
Difficult y getting breath out is indicative of air trapping. Air trap ping
is described as a normal breathing pattern interspersed with forced
expirations. As the patient breathes, air becomes trapped in the lungs,
and ventilations become progressivel y shallower until the patient
activel y and forcefully exhales.
PTS: 1 DIF: Cognitive Level: Appl ying REF: p. 433
OBJ: Nursing Process Step: Assessment TOP:
Pulmonary MSC: NC LEX: Physiologic Integrit y
