Question 1

During auscultation of breath sounds,the nurse should use the stethoscope correctly,in which of the following ways?

Accepted Answer

A)  Listen to at least one full respiration in each location. 
B)  Listen as the patient inhales and then go to the next site during exhalation. 
C)  Have the patient breathe in and out rapidly while the nurse listens to the breath sounds. 
D)  If the patient is modest, listen to sounds over his or her clothing or hospital gown. 
A)  Listen to at least one full respiration in each location. 
B)  Listen as the patient inhales and then go to the next site during exhalation. 
C)  Have the patient breathe in and out rapidly while the nurse listens to the breath sounds. 
D)  If the patient is modest, listen to sounds over his or her clothing or hospital gown. A

Question 2

The nurse knows that a normal finding when assessing the respiratory system of an elderly adult is:

Accepted Answer

A)  increased thoracic expansion. 
B)  decreased mobility of the thorax. 
C)  a decreased anteroposterior diameter. 
D)  bronchovesicular breath sounds throughout the lungs. 
A)  increased thoracic expansion. 
B)  decreased mobility of the thorax. 
C)  a decreased anteroposterior diameter. 
D)  bronchovesicular breath sounds throughout the lungs. B

Question 3

When assessing the respiratory system of a 4-year-old child,which of these findings would the nurse expect?

Accepted Answer

A)  Crepitus palpated at the costochondral junctions 
B)  No diaphragmatic excursion as a result of a child's decreased inspiratory volume 
C)  The presence of bronchovesicular breath sounds in the peripheral lung fields 
D)  An irregular respiratory pattern and a respiratory rate of 40 breaths per minute at rest 
A)  Crepitus palpated at the costochondral junctions 
B)  No diaphragmatic excursion as a result of a child's decreased inspiratory volume 
C)  The presence of bronchovesicular breath sounds in the peripheral lung fields 
D)  An irregular respiratory pattern and a respiratory rate of 40 breaths per minute at rest C

Question 4

The primary muscles of respiration include the:

Accepted Answer

A)  diaphragm and intercostals. 
B)  sternomastoids and scaleni. 
C)  trapezius and rectus abdominis. 
D)  external obliques and pectoralis major. 
A)  diaphragm and intercostals. 
B)  sternomastoids and scaleni. 
C)  trapezius and rectus abdominis. 
D)  external obliques and pectoralis major.

Question 5

The nurse is assessing the lungs of an older adult.Which of these describes normal changes in the respiratory system of the older adult?

Accepted Answer

A)  Severe dyspnea is experienced on exertion resulting from changes in the lungs. 
B)  Respiratory muscle strength increases to compensate for a decreased vital capacity. 
C)  There is a decrease in small airway closure, leading to problems with atelectasis. 
D)  The lungs are less elastic and distensible, which decreases their ability to collapse and recoil. 
A)  Severe dyspnea is experienced on exertion resulting from changes in the lungs. 
B)  Respiratory muscle strength increases to compensate for a decreased vital capacity. 
C)  There is a decrease in small airway closure, leading to problems with atelectasis. 
D)  The lungs are less elastic and distensible, which decreases their ability to collapse and recoil.

Question 6

The nurse is percussing over the lungs of a patient with pneumonia.The nurse knows that percussion over an area of atelectasis in the lungs would reveal:

Accepted Answer

A)  dullness. 
B)  tympany. 
C)  resonance. 
D)  hyperresonance. 
A)  dullness. 
B)  tympany. 
C)  resonance. 
D)  hyperresonance.

Question 7

The nurse is reviewing the technique of palpating for tactile fremitus with a new graduate.Which statement by the graduate nurse reflects a correct understanding of tactile fremitus? "Tactile fremitus:

Accepted Answer

A)  is caused by moisture in the alveoli." 
B)  indicates that there is air in the subcutaneous tissues." 
C)  is caused by sounds generated from the larynx." 
D)  reflects the blood flow through the pulmonary arteries." 
A)  is caused by moisture in the alveoli." 
B)  indicates that there is air in the subcutaneous tissues." 
C)  is caused by sounds generated from the larynx." 
D)  reflects the blood flow through the pulmonary arteries."

Question 8

A 65-year-old patient with a history of heart failure comes to the clinic with complaints of "being awakened from sleep with shortness of breath." Which action by the nurse is most appropriate?

Accepted Answer

A)  Obtain a detailed history of the patient's allergies and history of asthma. 
B)  Tell the patient to sleep on his or her right side to facilitate ease of respirations. 
C)  Assess for other signs and symptoms of paroxysmal nocturnal dyspnea. 
D)  Assure the patient that this is normal and will probably resolve within the next week. 
A)  Obtain a detailed history of the patient's allergies and history of asthma. 
B)  Tell the patient to sleep on his or her right side to facilitate ease of respirations. 
C)  Assess for other signs and symptoms of paroxysmal nocturnal dyspnea. 
D)  Assure the patient that this is normal and will probably resolve within the next week.

Question 9

The nurse notes hyperresonant percussion tones when percussing the thorax of an infant.The nurse's best action would be to:

Accepted Answer

A)  notify the physician. 
B)  suspect a pneumothorax. 
C)  consider this a normal finding. 
D)  monitor the infant's respiratory rate and rhythm. 
A)  notify the physician. 
B)  suspect a pneumothorax. 
C)  consider this a normal finding. 
D)  monitor the infant's respiratory rate and rhythm.

Question 10

During auscultation of the lungs of an adult patient,the nurse notices the presence of bronchophony.The nurse should assess for signs of which condition?

Accepted Answer

A)  Airway obstruction 
B)  Emphysema 
C)  Pulmonary consolidation 
D)  Asthma 
A)  Airway obstruction 
B)  Emphysema 
C)  Pulmonary consolidation 
D)  Asthma

Question 11

A patient comes to the clinic complaining of a cough that is worse at night but not as bad during the day.The nurse recognizes that this may indicate:

Accepted Answer

A)  pneumonia. 
B)  postnasal drip or sinusitis. 
C)  exposure to irritants at work. 
D)  chronic bronchial irritation from smoking. 
A)  pneumonia. 
B)  postnasal drip or sinusitis. 
C)  exposure to irritants at work. 
D)  chronic bronchial irritation from smoking.

Question 12

A teenage patient comes to the emergency department with complaints of an inability to breathe and a sharp pain in the left side of his chest.The assessment findings include cyanosis,tachypnea,tracheal deviation to the right,decreased tactile fremitus on the left,hyperresonance on the left,and decreased breath sounds on the left.The nurse interprets that these assessment findings are consistent with:

Accepted Answer

A)  bronchitis. 
B)  a pneumothorax. 
C)  acute pneumonia. 
D)  an asthmatic attack. 
A)  bronchitis. 
B)  a pneumothorax. 
C)  acute pneumonia. 
D)  an asthmatic attack.

Question 13

When assessing a patient's lungs,the nurse recalls that the left lung:

Accepted Answer

A)  consists of two lobes. 
B)  is divided by the horizontal fissure. 
C)  consists primarily of an upper lobe on the posterior chest. 
D)  is shorter than the right lung because of the underlying stomach. 
A)  consists of two lobes. 
B)  is divided by the horizontal fissure. 
C)  consists primarily of an upper lobe on the posterior chest. 
D)  is shorter than the right lung because of the underlying stomach.

Question 14

A 70-year-old patient is being seen in the clinic for severe exacerbation of his heart failure.Which of these findings is the nurse most likely to observe in this situation?

Accepted Answer

A)  Shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, ankle edema 
B)  Rasping cough, thick mucoid sputum, wheezing, bronchitis 
C)  Productive cough, dyspnea, weight loss, anorexia, tuberculosis 
D)  Fever, dry nonproductive cough, diminished breath sounds 
A)  Shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, ankle edema 
B)  Rasping cough, thick mucoid sputum, wheezing, bronchitis 
C)  Productive cough, dyspnea, weight loss, anorexia, tuberculosis 
D)  Fever, dry nonproductive cough, diminished breath sounds

Question 15

Which statement about the apices of the lungs is true? The apices of the lungs:

Accepted Answer

A)  are at the level of the second rib anteriorly. 
B)  extend 3 to 4 cm above the inner third of the clavicles. 
C)  are located at the sixth rib anteriorly and the eighth rib laterally. 
D)  rest on the diaphragm at the fifth intercostal space in the midclavicular line. 
A)  are at the level of the second rib anteriorly. 
B)  extend 3 to 4 cm above the inner third of the clavicles. 
C)  are located at the sixth rib anteriorly and the eighth rib laterally. 
D)  rest on the diaphragm at the fifth intercostal space in the midclavicular line.

Question 16

An adult patient with a history of allergies comes to the clinic complaining of wheezing and difficulty in breathing when working in his yard.The assessment findings include tachypnea,use of accessory neck muscles,prolonged expiration,intercostal retractions,decreased breath sounds,and expiratory wheezes.The nurse interprets that these assessment findings are consistent with:

Accepted Answer

A)  asthma. 
B)  atelectasis. 
C)  lobar pneumonia. 
D)  heart failure. 
A)  asthma. 
B)  atelectasis. 
C)  lobar pneumonia. 
D)  heart failure.

Question 17

A patient has a long history of chronic obstructive pulmonary disease.During the assessment,the nurse is most likely to observe which of these?

Accepted Answer

A)  Unequal chest expansion 
B)  Increased tactile fremitus 
C)  Atrophied neck and trapezius muscles 
D)  An anteroposterior-to-transverse diameter ratio of 1:1 
A)  Unequal chest expansion 
B)  Increased tactile fremitus 
C)  Atrophied neck and trapezius muscles 
D)  An anteroposterior-to-transverse diameter ratio of 1:1

Question 18

A woman in her 26th week of pregnancy states that she is "not really short of breath" but feels that she is aware of her breathing and the need to breathe.What is the nurse's best reply?

Accepted Answer

A)  "The diaphragm becomes fixed during pregnancy, making it difficult to take in a deep breath." 
B)  "The increase in estrogen levels during pregnancy often causes a decrease in the diameter of the rib cage and makes it difficult to breathe." 
C)  "What you are experiencing is normal. Some women may interpret this as shortness of breath, but it is a normal finding and nothing is wrong." 
D)  "This is normal as the fetus grows because of the increased oxygen demand on the mother's body and results in an increased respiratory rate." 
A)  "The diaphragm becomes fixed during pregnancy, making it difficult to take in a deep breath." 
B)  "The increase in estrogen levels during pregnancy often causes a decrease in the diameter of the rib cage and makes it difficult to breathe." 
C)  "What you are experiencing is normal. Some women may interpret this as shortness of breath, but it is a normal finding and nothing is wrong." 
D)  "This is normal as the fetus grows because of the increased oxygen demand on the mother's body and results in an increased respiratory rate."

Question 19

When inspecting the anterior chest of an adult,the nurse should include which assessment?

Accepted Answer

A)  Diaphragmatic excursion 
B)  Symmetric chest expansion 
C)  The presence of breath sounds 
D)  The shape and configuration of the chest wall 
A)  Diaphragmatic excursion 
B)  Symmetric chest expansion 
C)  The presence of breath sounds 
D)  The shape and configuration of the chest wall

Question 20

A patient with pleuritis has been admitted to the hospital and complains of pain with breathing.What other key assessment finding would the nurse expect to find upon auscultation?

Accepted Answer

A)  Stridor 
B)  Friction rub 
C)  Crackles 
D)  Wheezing 
A)  Stridor 
B)  Friction rub 
C)  Crackles 
D)  Wheezing

Exam 18: Thorax and Lungs

During auscultation of breath sounds,the nurse should use the stethoscope correctly,in which of the following ways?

The nurse knows that a normal finding when assessing the respiratory system of an elderly adult is:

When assessing the respiratory system of a 4-year-old child,which of these findings would the nurse expect?

The primary muscles of respiration include the:

The nurse is assessing the lungs of an older adult.Which of these describes normal changes in the respiratory system of the older adult?

The nurse is percussing over the lungs of a patient with pneumonia.The nurse knows that percussion over an area of atelectasis in the lungs would reveal:

The nurse is reviewing the technique of palpating for tactile fremitus with a new graduate.Which statement by the graduate nurse reflects a correct understanding of tactile fremitus? "Tactile fremitus:

A 65-year-old patient with a history of heart failure comes to the clinic with complaints of "being awakened from sleep with shortness of breath." Which action by the nurse is most appropriate?

The nurse notes hyperresonant percussion tones when percussing the thorax of an infant.The nurse's best action would be to:

During auscultation of the lungs of an adult patient,the nurse notices the presence of bronchophony.The nurse should assess for signs of which condition?

A patient comes to the clinic complaining of a cough that is worse at night but not as bad during the day.The nurse recognizes that this may indicate:

When assessing a patient's lungs,the nurse recalls that the left lung:

A 70-year-old patient is being seen in the clinic for severe exacerbation of his heart failure.Which of these findings is the nurse most likely to observe in this situation?

Which statement about the apices of the lungs is true? The apices of the lungs:

A patient has a long history of chronic obstructive pulmonary disease.During the assessment,the nurse is most likely to observe which of these?

A woman in her 26th week of pregnancy states that she is "not really short of breath" but feels that she is aware of her breathing and the need to breathe.What is the nurse's best reply?

When inspecting the anterior chest of an adult,the nurse should include which assessment?

A patient with pleuritis has been admitted to the hospital and complains of pain with breathing.What other key assessment finding would the nurse expect to find upon auscultation?

Evidence Based Assessment

Cultural Competence: Cultural Care

The Interview

The Complete Health History

Mental Status Assessment

Substance Use Assessment

Domestic Violence Assessment

Assessment Techniques and the Clinical Setting

General Survey, Measurement, Vital Signs

Pain Assessment: The Fifth Vital Sign

Nutritional Assessment

Skin, Hair, and Nails

Head, Face, and Neck, Including Regional Lymphatics

Eyes

Ears

Nose, Mouth, and Throat

Breasts and Regional Lymphatics

Heart and Neck Vessels

Peripheral Vascular System and Lymphatic System

Abdomen

Musculoskeletal System

Neurologic System

Male Genitourinary System

Anus, Rectum, and Prostate

Female Genitourinary System

The Complete Health Assessment: Putting It All Together

Bedside Assessment of the Hospitalized Adult

The Pregnant Woman

Functional Assessment of the Older Adult

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