Chapter 25: Assessment of Respiratory System Lewis:
Medical-Surgical Nursing, 10th Edition UPDATED
ACTUAL Questions and CORRECT Answers
A patient with acute shortness of breath is admitted to ANS: B
the hospital. Which action should the When a patient has severe respiratory distress, only information pertinent to the
nurse take during the initial assessment of the patient? current
a. Ask the patient to lie down to complete a full physical episode is obtained, and a more thorough assessment is deferred until later.
assessment. Obtaining a
b. Briefly ask specific questions about this episode of comprehensive health history or full physical examination is unnecessary until
respiratory distress. the acute
c. Complete the admission database to check for distress has resolved. Brief questioning and a focused physical assessment
allergies before treatment. should be done
d. Delay the physical assessment to first complete rapidly to help determine the cause of the distress and suggest treatment.
pulmonary function tests. 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
The nurse prepares a patient with a left-sided pleural ANS: D
effusion for a thoracentesis. How should The upright position with the arms supported increases lung expansion, allows
the nurse position the patient? fluid to collect
a. High-Fowler's position with the left arm extended at the lung bases, and expands the intercostal space so that access to the
b. Supine with the head of the bed elevated 30 degrees pleural space is
c. On the right side with the left arm extended above easier. The other positions would increase the work of breathing for the patient
the head and make it
d. Sitting upright with the arms supported on an over more difficult for the health care provider performing the thoracentesis.
bed table DIF: Cognitive Level: Apply (application) REF: 471
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
, A diabetic patient's arterial blood gas (ABG) results are ANS: B
pH 7.28; PaCO2 34 mm Hg; PaO2 85 mm Hg; HCO3- 18
mEq/L. The nurse would expect which finding? Kussmaul (deep and rapid) respirations are a compensatory mechanism for
metabolic
a. Intercostal retractions c. Low oxygen saturation acidosis. The low pH and low bicarbonate result indicate metabolic acidosis.
(SpO2) Intercostal
b. Kussmaul respirations d. Decreased venous O2 retractions, a low oxygen saturation rate, and a decrease in venous O2 pressure
pressure would not be
caused by acidosis.
DIF: Cognitive Level: Apply (application) REF: 467
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
On auscultation of a patient's lungs, the nurse hears ANS: A
low-pitched, bubbling sounds during Crackles are low-pitched, bubbling sounds usually heard on inspiration.
inhalation in the lower third of both lungs. How should Wheezes are
the nurse document this finding? high-pitched sounds. They can be heard during the expiratory or inspiratory
a. Inspiratory crackles at the bases phase of the
b. Expiratory wheezes in both lungs respiratory cycle. The lower third of both lungs are the bases, not apices.
c. Abnormal lung sounds in the apices of both lungs Pleural friction rubs
d. Pleural friction rub in the right and left lower lobes 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
The nurse palpates the posterior chest while the patient ANS: D
says "99" and notes absent fremitus. To assess for tactile fremitus, the nurse should use the palms of the hands to
Which action should the nurse take next? assess for
a. Palpate the anterior chest and observe for barrel vibration when the patient repeats a word or phrase such as "99." After noting
chest. absent fremitus,
b. Encourage the patient to turn, cough, and deep the nurse should then auscultate the lungs to assess for the presence or
breathe. absence of breath
c. Review the chest x-ray report for evidence of sounds. Absent fremitus may be noted with pneumothorax or atelectasis. The
pneumonia. vibration is
d. Auscultate anterior and posterior breath sounds increased in conditions such as pneumonia, lung tumors, thick bronchial
bilaterally. 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 Integrity
A patient with a chronic cough is scheduled to have a ANS: C
bronchoscopy with biopsy. Which Risk for aspiration and maintaining an open airway is the priority. Because a
intervention will the nurse implement directly after the local anesthetic
procedure? is used to suppress the gag and cough reflexes during bronchoscopy, the
a. Encourage the patient to drink clear liquids. nurse should monitor
b. Place the patient on bed rest for at least 4 hours. for the return of these reflexes before allowing the patient to take oral fluids or
c. Keep the patient NPO until the gag reflex returns. food. The
d. Maintain the head of the bed elevated 90 degrees. patient does not need to be on bed rest, and the head of the bed does not
need to be in the
high-Fowler's position.
DIF: Cognitive Level: Apply (application) REF: 470
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
Medical-Surgical Nursing, 10th Edition UPDATED
ACTUAL Questions and CORRECT Answers
A patient with acute shortness of breath is admitted to ANS: B
the hospital. Which action should the When a patient has severe respiratory distress, only information pertinent to the
nurse take during the initial assessment of the patient? current
a. Ask the patient to lie down to complete a full physical episode is obtained, and a more thorough assessment is deferred until later.
assessment. Obtaining a
b. Briefly ask specific questions about this episode of comprehensive health history or full physical examination is unnecessary until
respiratory distress. the acute
c. Complete the admission database to check for distress has resolved. Brief questioning and a focused physical assessment
allergies before treatment. should be done
d. Delay the physical assessment to first complete rapidly to help determine the cause of the distress and suggest treatment.
pulmonary function tests. 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
The nurse prepares a patient with a left-sided pleural ANS: D
effusion for a thoracentesis. How should The upright position with the arms supported increases lung expansion, allows
the nurse position the patient? fluid to collect
a. High-Fowler's position with the left arm extended at the lung bases, and expands the intercostal space so that access to the
b. Supine with the head of the bed elevated 30 degrees pleural space is
c. On the right side with the left arm extended above easier. The other positions would increase the work of breathing for the patient
the head and make it
d. Sitting upright with the arms supported on an over more difficult for the health care provider performing the thoracentesis.
bed table DIF: Cognitive Level: Apply (application) REF: 471
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
, A diabetic patient's arterial blood gas (ABG) results are ANS: B
pH 7.28; PaCO2 34 mm Hg; PaO2 85 mm Hg; HCO3- 18
mEq/L. The nurse would expect which finding? Kussmaul (deep and rapid) respirations are a compensatory mechanism for
metabolic
a. Intercostal retractions c. Low oxygen saturation acidosis. The low pH and low bicarbonate result indicate metabolic acidosis.
(SpO2) Intercostal
b. Kussmaul respirations d. Decreased venous O2 retractions, a low oxygen saturation rate, and a decrease in venous O2 pressure
pressure would not be
caused by acidosis.
DIF: Cognitive Level: Apply (application) REF: 467
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
On auscultation of a patient's lungs, the nurse hears ANS: A
low-pitched, bubbling sounds during Crackles are low-pitched, bubbling sounds usually heard on inspiration.
inhalation in the lower third of both lungs. How should Wheezes are
the nurse document this finding? high-pitched sounds. They can be heard during the expiratory or inspiratory
a. Inspiratory crackles at the bases phase of the
b. Expiratory wheezes in both lungs respiratory cycle. The lower third of both lungs are the bases, not apices.
c. Abnormal lung sounds in the apices of both lungs Pleural friction rubs
d. Pleural friction rub in the right and left lower lobes 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
The nurse palpates the posterior chest while the patient ANS: D
says "99" and notes absent fremitus. To assess for tactile fremitus, the nurse should use the palms of the hands to
Which action should the nurse take next? assess for
a. Palpate the anterior chest and observe for barrel vibration when the patient repeats a word or phrase such as "99." After noting
chest. absent fremitus,
b. Encourage the patient to turn, cough, and deep the nurse should then auscultate the lungs to assess for the presence or
breathe. absence of breath
c. Review the chest x-ray report for evidence of sounds. Absent fremitus may be noted with pneumothorax or atelectasis. The
pneumonia. vibration is
d. Auscultate anterior and posterior breath sounds increased in conditions such as pneumonia, lung tumors, thick bronchial
bilaterally. 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 Integrity
A patient with a chronic cough is scheduled to have a ANS: C
bronchoscopy with biopsy. Which Risk for aspiration and maintaining an open airway is the priority. Because a
intervention will the nurse implement directly after the local anesthetic
procedure? is used to suppress the gag and cough reflexes during bronchoscopy, the
a. Encourage the patient to drink clear liquids. nurse should monitor
b. Place the patient on bed rest for at least 4 hours. for the return of these reflexes before allowing the patient to take oral fluids or
c. Keep the patient NPO until the gag reflex returns. food. The
d. Maintain the head of the bed elevated 90 degrees. patient does not need to be on bed rest, and the head of the bed does not
need to be in the
high-Fowler's position.
DIF: Cognitive Level: Apply (application) REF: 470
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
