C HAPTER 13: P ULMONARY C LINICAL
A SSESSMENT AND D IAGNOSTIC P ROCEDURES
Urden: Priorities in Critical Care Nursing, 8th Edition
MULTIPLE CHOICE
1. 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: Anal yzing OBJ: Nursing
Process Step: Assessment TOP: Pulmonary Clinical
Assessment and Diagnostic Procedures MSC: NC LEX:
Physiological Integrity: Reduction of Risk Potential
,2. A patient just involved in a motor vehicle accident has sustained blunt
chest trauma as part of his injuries. The nurse notes absent breath
sounds on the left side. A left -sided pneumothorax is suspected and is
further validated when assessment of the trachea reveals what finding?
a. A shift to the right
b. A shift to the left
c. No deviation
d. Subcutaneous emphysema
ANS: A
With a pneumothorax, the trachea shifts to the opposite side of the
problem; with atelectasis, the trachea shifts to the same side as the
problem. Subcutaneous emphysema is more commonl y related to a
pneumomediastinum and is not specific ally related to the trachea but to
air trapped in the mediastinum and general neck area.
PTS: 1 DIF: Cognitive Level: Anal yzing OBJ: Nursing
Process Step: Assessment TOP: Pulmonary Clinical
Assessment and Diagnostic Procedures MSC: NC LEX:
Physiological Integrity: Reduction of Risk Potential
3. The nurse is caring for a patient with respiratory failure. The nurse
notes the patient’s diaphragmatic excursing is 8 cm. What coexisting
conditions could account for this finding?
a. Asthma and emphysema
b. Hepatomegal y and ascites
c. Atelectasis and pleural effusion
d. Pneumonia and pneumothorax
, ANS: C
Normal diaphragmatic excursion is 3 to 5 cm and is part of the
percussion component of the physical examination. Diaphragmatic
excursion is increased in pleural effusion, and disorders that elevate
the diaphragm, such as atelectasis or paralysis. Diaphragmatic
excursion is decreased in disorders such as ascites, pregnancy,
hepatomegal y, and emphysema.
PTS: 1 DIF: Cognitive Level: Anal yzing OBJ: Nursing
Process Step: Assessment TOP: Pulmonary Clinical
Assessment and Diagnostic Procedures MSC: NC LEX:
Physiological Integrity: Reduction of Risk Potential
4. The nurse is observing a new nurse listen to a patient’s lungs. Which
action by the new nurse indicates a need to re view auscultation skills?
a. The nurse starts at the apices and moves to the bases.
b. The nurse compares breath sounds from side to side.
c. The nurse listens only during inspiration.
d. The nurse listens posteriorl y, laterall y, and anteriorl y.
ANS: C
Breath sounds are assessed during both inspiration and expiration.
Auscultation is done in a systematic sequence: side -to-side, top -to-
bottom, posteriorl y, laterall y, and anteriorl y.
PTS: 1 DIF: Cognitive Level: Appl ying OBJ: Nursing
Process Step: Assessment TOP: Pulmonary Clinical
A SSESSMENT AND D IAGNOSTIC P ROCEDURES
Urden: Priorities in Critical Care Nursing, 8th Edition
MULTIPLE CHOICE
1. 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: Anal yzing OBJ: Nursing
Process Step: Assessment TOP: Pulmonary Clinical
Assessment and Diagnostic Procedures MSC: NC LEX:
Physiological Integrity: Reduction of Risk Potential
,2. A patient just involved in a motor vehicle accident has sustained blunt
chest trauma as part of his injuries. The nurse notes absent breath
sounds on the left side. A left -sided pneumothorax is suspected and is
further validated when assessment of the trachea reveals what finding?
a. A shift to the right
b. A shift to the left
c. No deviation
d. Subcutaneous emphysema
ANS: A
With a pneumothorax, the trachea shifts to the opposite side of the
problem; with atelectasis, the trachea shifts to the same side as the
problem. Subcutaneous emphysema is more commonl y related to a
pneumomediastinum and is not specific ally related to the trachea but to
air trapped in the mediastinum and general neck area.
PTS: 1 DIF: Cognitive Level: Anal yzing OBJ: Nursing
Process Step: Assessment TOP: Pulmonary Clinical
Assessment and Diagnostic Procedures MSC: NC LEX:
Physiological Integrity: Reduction of Risk Potential
3. The nurse is caring for a patient with respiratory failure. The nurse
notes the patient’s diaphragmatic excursing is 8 cm. What coexisting
conditions could account for this finding?
a. Asthma and emphysema
b. Hepatomegal y and ascites
c. Atelectasis and pleural effusion
d. Pneumonia and pneumothorax
, ANS: C
Normal diaphragmatic excursion is 3 to 5 cm and is part of the
percussion component of the physical examination. Diaphragmatic
excursion is increased in pleural effusion, and disorders that elevate
the diaphragm, such as atelectasis or paralysis. Diaphragmatic
excursion is decreased in disorders such as ascites, pregnancy,
hepatomegal y, and emphysema.
PTS: 1 DIF: Cognitive Level: Anal yzing OBJ: Nursing
Process Step: Assessment TOP: Pulmonary Clinical
Assessment and Diagnostic Procedures MSC: NC LEX:
Physiological Integrity: Reduction of Risk Potential
4. The nurse is observing a new nurse listen to a patient’s lungs. Which
action by the new nurse indicates a need to re view auscultation skills?
a. The nurse starts at the apices and moves to the bases.
b. The nurse compares breath sounds from side to side.
c. The nurse listens only during inspiration.
d. The nurse listens posteriorl y, laterall y, and anteriorl y.
ANS: C
Breath sounds are assessed during both inspiration and expiration.
Auscultation is done in a systematic sequence: side -to-side, top -to-
bottom, posteriorl y, laterall y, and anteriorl y.
PTS: 1 DIF: Cognitive Level: Appl ying OBJ: Nursing
Process Step: Assessment TOP: Pulmonary Clinical
