Lewis's Medical Surgical Nursing Test Bank 11th Edition [Harding]
Chapter 25 - Assessment: Respiratory System
1. 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. Ask the patient to lie down to complete a full physical assessment.
B. Briefly ask specific questions about this episode of respiratory distress.
C. Complete the admission database to check for allergies before treatment.
D. Delay the physical assessment to first complete pulmonary function tests.
Answer: B
Explanation: In acute respiratory distress, the nurse should perform a focused assessment to
quickly identify the cause and initiate treatment. A full history and physical can be completed
once the patient is stabilized.
2. The nurse prepares a patient with a left-sided pleural effusion for a
thoracentesis. How should the nurse position the patient?
A. Supine with the head of the bed elevated 30 degrees
B. In a high-Fowlers position with the left arm extended
C. On the right side with the left arm extended above the head
D. Sitting upright with the arms supported on an over bed table
Answer: D
Explanation: The sitting upright position with arms supported on an over-bed table expands
the intercostal spaces and allows fluid to collect at the lung bases, facilitating easier and safer
access for the procedure.
3. A diabetic patients arterial blood gas (ABG) results are pH 7.28; PaCO₂ 34 mm
Hg; PaO₂ 85 mm Hg; HCO₃ 18 mEq/L. The nurse would expect which finding?
A. Intercostal retractions
B. Kussmaul respirations
C. Low oxygen saturation (SpO₂)
D. Decreased venous O₂ pressure
Answer: B
Explanation: The ABG indicates metabolic acidosis (low pH and low HCO₃). Kussmaul
respirations (deep and rapid breathing) are a compensatory mechanism to exhale excess CO₂
and correct acidosis.
, 4. On auscultation of a patients lungs, the nurse hears low-pitched, bubbling
sounds during inhalation in the lower third of both lungs. How should the nurse
document this finding?
A. Inspiratory crackles at the bases
B. Expiratory wheezes in both lungs
C. Abnormal lung sounds in the apices of both lungs
D. Pleural friction rub in the right and left lower lobes
Answer: A
Explanation: Crackles are low-pitched, bubbling sounds typically heard on inspiration. When
located in the lower third of the lungs, they are documented as "inspiratory crackles at the
bases."
5. The nurse palpates the posterior chest while the patient says 99 and notes absent
fremitus. Which action should the nurse take next?
A. Palpate the anterior chest and observe for barrel chest.
B. Encourage the patient to turn, cough, and deep breathe.
C. Review the chest x-ray report for evidence of pneumonia.
D. Auscultate anterior and posterior breath sounds bilaterally.
Answer: D
Explanation: Absent fremitus can indicate conditions like pneumothorax or atelectasis. The
nurse should immediately auscultate breath sounds to assess for presence, absence, or
abnormality of air movement.
6. A patient with a chronic cough has a bronchoscopy. After the procedure, which
intervention by the nurse is most appropriate?
A. Elevate the head of the bed to 80 to 90 degrees.
B. Keep the patient NPO until the gag reflex returns.
C. Place on bed rest for at least 4 hours after bronchoscopy.
D. Notify the health care provider about blood-tinged mucus.
Answer: B
Explanation: The local anesthetic used during bronchoscopy suppresses the gag and cough
reflexes. Keeping the patient NPO until these reflexes return prevents aspiration.
7. The nurse completes a shift assessment on a patient admitted in the early phase
of heart failure. When auscultating the patients lungs, which finding would the
nurse most likely hear?
A. Continuous rumbling, snoring, or rattling sounds mainly on expiration
, B. Continuous high-pitched musical sounds on inspiration and expiration
C. Discontinuous, high-pitched sounds of short duration heard on inspiration
D. A series of long-duration, discontinuous, low-pitched sounds during inspiration
Answer: C
Explanation: Fine crackles (discontinuous, high-pitched, short sounds on inspiration) are
commonly heard in early heart failure due to fluid leakage into the alveoli.
8. While caring for a patient with respiratory disease, the nurse observes that the
patients SpO₂ drops from 93% to 88% while the patient is ambulating in the
hallway. What is the priority action of the nurse?
A. Notify the health care provider.
B. Document the response to exercise.
C. Administer the PRN supplemental O₂.
D. Encourage the patient to pace activity.
Answer: C
Explanation: An SpO₂ of 88% indicates significant hypoxemia. The priority is to correct
oxygenation by administering supplemental oxygen as needed.
9. The nurse teaches a patient about pulmonary function testing (PFT). Which
statement, if made by the patient, indicates teaching was effective?
A. I will use my inhaler right before the test.
B. I won't eat or drink anything 8 hours before the test.
C. I should inhale deeply and blow out as hard as I can during the test.
D. My blood pressure and pulse will be checked every 15 minutes after the test.
Answer: C
Explanation: PFT requires maximal patient effort; inhaling deeply and exhaling as hard and
fast as possible is essential for accurate results. Bronchodilators should be withheld before the
test.
10. The nurse observes a student who is listening to a patients lungs who is having no
problems with breathing. Which action by the student indicates a need to review
respiratory assessment skills?
A. The student starts at the apices of the lungs and moves to the bases.
B. The student compares breath sounds from side to side avoiding bony areas.
C. The student places the stethoscope over the posterior chest and listens during
inspiration.
, D. The student instructs the patient to breathe slowly and a little more deeply than
normal through the mouth.
Answer: C
Explanation: The student should listen to a full cycle of inspiration and expiration at each
stethoscope placement. Listening only during inspiration is an incomplete assessment.
11. A patient who has a history of chronic obstructive pulmonary disease (COPD)
was hospitalized for increasing shortness of breath and chronic hypoxemia (SaO₂
levels of 89% to 90%). In planning for discharge, which action by the nurse will
be most effective in improving compliance with discharge teaching?
A. Start giving the patient discharge teaching on the day of admission.
B. Have the patient repeat the instructions immediately after teaching.
C. Accomplish the patient teaching just before the scheduled discharge.
D. Arrange for the patients caregiver to be present during the teaching.
Answer: D
Explanation: Chronic hypoxemia can impair cognition and memory. Involving a caregiver
ensures that instructions are understood and can be reinforced at home.
12. A patient is admitted to the emergency department complaining of sudden onset
shortness of breath and is diagnosed with a possible pulmonary embolus. How
should the nurse prepare the patient for diagnostic testing to confirm the
diagnosis?
A. Start an IV so contrast media may be given.
B. Ensure that the patient has been NPO for at least 6 hours.
C. Inform radiology that radioactive glucose preparation is needed.
D. Instruct the patient to undress to the waist and remove any metal objects.
Answer: A
Explanation: A spiral CT scan, the primary test for pulmonary embolism, requires IV
contrast. Starting an IV ensures readiness for the procedure.
13. The nurse admits a patient who has a diagnosis of an acute asthma attack.
Which statement indicates that the patient may need teaching regarding
medication use?
A. I have not had any acute asthma attacks during the last year.
B. I became short of breath an hour before coming to the hospital.
C. Ive been taking Tylenol 650 mg every 6 hours for chest-wall pain.
D. Ive been using my albuterol inhaler more frequently over the last 4 days.
Chapter 25 - Assessment: Respiratory System
1. 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. Ask the patient to lie down to complete a full physical assessment.
B. Briefly ask specific questions about this episode of respiratory distress.
C. Complete the admission database to check for allergies before treatment.
D. Delay the physical assessment to first complete pulmonary function tests.
Answer: B
Explanation: In acute respiratory distress, the nurse should perform a focused assessment to
quickly identify the cause and initiate treatment. A full history and physical can be completed
once the patient is stabilized.
2. The nurse prepares a patient with a left-sided pleural effusion for a
thoracentesis. How should the nurse position the patient?
A. Supine with the head of the bed elevated 30 degrees
B. In a high-Fowlers position with the left arm extended
C. On the right side with the left arm extended above the head
D. Sitting upright with the arms supported on an over bed table
Answer: D
Explanation: The sitting upright position with arms supported on an over-bed table expands
the intercostal spaces and allows fluid to collect at the lung bases, facilitating easier and safer
access for the procedure.
3. A diabetic patients arterial blood gas (ABG) results are pH 7.28; PaCO₂ 34 mm
Hg; PaO₂ 85 mm Hg; HCO₃ 18 mEq/L. The nurse would expect which finding?
A. Intercostal retractions
B. Kussmaul respirations
C. Low oxygen saturation (SpO₂)
D. Decreased venous O₂ pressure
Answer: B
Explanation: The ABG indicates metabolic acidosis (low pH and low HCO₃). Kussmaul
respirations (deep and rapid breathing) are a compensatory mechanism to exhale excess CO₂
and correct acidosis.
, 4. On auscultation of a patients lungs, the nurse hears low-pitched, bubbling
sounds during inhalation in the lower third of both lungs. How should the nurse
document this finding?
A. Inspiratory crackles at the bases
B. Expiratory wheezes in both lungs
C. Abnormal lung sounds in the apices of both lungs
D. Pleural friction rub in the right and left lower lobes
Answer: A
Explanation: Crackles are low-pitched, bubbling sounds typically heard on inspiration. When
located in the lower third of the lungs, they are documented as "inspiratory crackles at the
bases."
5. The nurse palpates the posterior chest while the patient says 99 and notes absent
fremitus. Which action should the nurse take next?
A. Palpate the anterior chest and observe for barrel chest.
B. Encourage the patient to turn, cough, and deep breathe.
C. Review the chest x-ray report for evidence of pneumonia.
D. Auscultate anterior and posterior breath sounds bilaterally.
Answer: D
Explanation: Absent fremitus can indicate conditions like pneumothorax or atelectasis. The
nurse should immediately auscultate breath sounds to assess for presence, absence, or
abnormality of air movement.
6. A patient with a chronic cough has a bronchoscopy. After the procedure, which
intervention by the nurse is most appropriate?
A. Elevate the head of the bed to 80 to 90 degrees.
B. Keep the patient NPO until the gag reflex returns.
C. Place on bed rest for at least 4 hours after bronchoscopy.
D. Notify the health care provider about blood-tinged mucus.
Answer: B
Explanation: The local anesthetic used during bronchoscopy suppresses the gag and cough
reflexes. Keeping the patient NPO until these reflexes return prevents aspiration.
7. The nurse completes a shift assessment on a patient admitted in the early phase
of heart failure. When auscultating the patients lungs, which finding would the
nurse most likely hear?
A. Continuous rumbling, snoring, or rattling sounds mainly on expiration
, B. Continuous high-pitched musical sounds on inspiration and expiration
C. Discontinuous, high-pitched sounds of short duration heard on inspiration
D. A series of long-duration, discontinuous, low-pitched sounds during inspiration
Answer: C
Explanation: Fine crackles (discontinuous, high-pitched, short sounds on inspiration) are
commonly heard in early heart failure due to fluid leakage into the alveoli.
8. While caring for a patient with respiratory disease, the nurse observes that the
patients SpO₂ drops from 93% to 88% while the patient is ambulating in the
hallway. What is the priority action of the nurse?
A. Notify the health care provider.
B. Document the response to exercise.
C. Administer the PRN supplemental O₂.
D. Encourage the patient to pace activity.
Answer: C
Explanation: An SpO₂ of 88% indicates significant hypoxemia. The priority is to correct
oxygenation by administering supplemental oxygen as needed.
9. The nurse teaches a patient about pulmonary function testing (PFT). Which
statement, if made by the patient, indicates teaching was effective?
A. I will use my inhaler right before the test.
B. I won't eat or drink anything 8 hours before the test.
C. I should inhale deeply and blow out as hard as I can during the test.
D. My blood pressure and pulse will be checked every 15 minutes after the test.
Answer: C
Explanation: PFT requires maximal patient effort; inhaling deeply and exhaling as hard and
fast as possible is essential for accurate results. Bronchodilators should be withheld before the
test.
10. The nurse observes a student who is listening to a patients lungs who is having no
problems with breathing. Which action by the student indicates a need to review
respiratory assessment skills?
A. The student starts at the apices of the lungs and moves to the bases.
B. The student compares breath sounds from side to side avoiding bony areas.
C. The student places the stethoscope over the posterior chest and listens during
inspiration.
, D. The student instructs the patient to breathe slowly and a little more deeply than
normal through the mouth.
Answer: C
Explanation: The student should listen to a full cycle of inspiration and expiration at each
stethoscope placement. Listening only during inspiration is an incomplete assessment.
11. A patient who has a history of chronic obstructive pulmonary disease (COPD)
was hospitalized for increasing shortness of breath and chronic hypoxemia (SaO₂
levels of 89% to 90%). In planning for discharge, which action by the nurse will
be most effective in improving compliance with discharge teaching?
A. Start giving the patient discharge teaching on the day of admission.
B. Have the patient repeat the instructions immediately after teaching.
C. Accomplish the patient teaching just before the scheduled discharge.
D. Arrange for the patients caregiver to be present during the teaching.
Answer: D
Explanation: Chronic hypoxemia can impair cognition and memory. Involving a caregiver
ensures that instructions are understood and can be reinforced at home.
12. A patient is admitted to the emergency department complaining of sudden onset
shortness of breath and is diagnosed with a possible pulmonary embolus. How
should the nurse prepare the patient for diagnostic testing to confirm the
diagnosis?
A. Start an IV so contrast media may be given.
B. Ensure that the patient has been NPO for at least 6 hours.
C. Inform radiology that radioactive glucose preparation is needed.
D. Instruct the patient to undress to the waist and remove any metal objects.
Answer: A
Explanation: A spiral CT scan, the primary test for pulmonary embolism, requires IV
contrast. Starting an IV ensures readiness for the procedure.
13. The nurse admits a patient who has a diagnosis of an acute asthma attack.
Which statement indicates that the patient may need teaching regarding
medication use?
A. I have not had any acute asthma attacks during the last year.
B. I became short of breath an hour before coming to the hospital.
C. Ive been taking Tylenol 650 mg every 6 hours for chest-wall pain.
D. Ive been using my albuterol inhaler more frequently over the last 4 days.
