Question 1

Which of the following adventitious sounds would be produced by air passing through narrowed bronchioles?

Accepted Answer

A) Wheezes 
B) Bronchial sounds 
C) Bronchophony 
D) Whispered pectoriloquy 
A) Wheezes 
B) Bronchial sounds 
C) Bronchophony 
D) Whispered pectoriloquy

Question 2

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

Accepted Answer

A) "The diaphragm becomes fixed during pregnancy,making it difficult to take in deep breaths." 
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 nothing is wrong." 
D) "This is normal as the fetus grows because of the increased oxygen demand on the mother's body,which results in an increased respiratory rate." 
A) "The diaphragm becomes fixed during pregnancy,making it difficult to take in deep breaths." 
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 nothing is wrong." 
D) "This is normal as the fetus grows because of the increased oxygen demand on the mother's body,which results in an increased respiratory rate."

Question 3

MATCHING
The nurse is evaluating voice sounds during respiratory assessment.Match the assessment with the correct technique.

-The normal response is faint,muffled,and almost inaudible when the patient says "one,two,three" in a very soft voice.

Accepted Answer

A) Bronchophony 
B) Egophony 
C) Whispered pectoriloquy 
A) Bronchophony 
B) Egophony 
C) Whispered pectoriloquy

Question 4

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

Accepted Answer

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

Question 5

When auscultating the lungs of an adult patient,the nurse notes that over the posterior lower lobes,low-pitched,soft breath sounds are heard,with inspiration being longer than expiration.The nurse is aware that these are:

Accepted Answer

A) sounds normally auscultated over the trachea. 
B) bronchial breath sounds and are normal in that location. 
C) vesicular breath sounds and are normal in that location. 
D) bronchovesicular breath sounds and are normal in that location. 
A) sounds normally auscultated over the trachea. 
B) bronchial breath sounds and are normal in that location. 
C) vesicular breath sounds and are normal in that location. 
D) bronchovesicular breath sounds and are normal in that location.

Question 6

When assessing for tactile fremitus,over which location is it normal to feel tactile fremitus most intensely?

Accepted Answer

A) Between the scapulae 
B) Third intercostal space,midclavicular line 
C) Fifth intercostal space,midaxillary line 
D) Over the lower lobes,posterior side 
A) Between the scapulae 
B) Third intercostal space,midclavicular line 
C) Fifth intercostal space,midaxillary line 
D) Over the lower lobes,posterior side

Question 7

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 8

Which of the following about the vertebra prominens is true? The vertebra prominens is:

Accepted Answer

A) the spinous process of C7. 
B) usually not palpable in most individuals. 
C) opposite the interior border of the scapula. 
D) located next to the manubrium of the sternum. 
A) the spinous process of C7. 
B) usually not palpable in most individuals. 
C) opposite the interior border of the scapula. 
D) located next to the manubrium of the sternum.

Question 9

The nurse knows that expected assessment findings in the normal adult lung include:

Accepted Answer

A) adventitious sounds and limited chest expansion. 
B) increased tactile fremitus and dull percussion tones. 
C) muffled voice sounds and symmetrical tactile fremitus. 
D) absent voice sounds and hyperresonant percussion tones. 
A) adventitious sounds and limited chest expansion. 
B) increased tactile fremitus and dull percussion tones. 
C) muffled voice sounds and symmetrical tactile fremitus. 
D) absent voice sounds and hyperresonant percussion tones.

Question 10

During palpation of the anterior chest wall,the nurse notes a coarse,crackling sensation over the skin surface and suspects:

Accepted Answer

A) tactile fremitus. 
B) crepitus. 
C) friction rub. 
D) adventitious sounds. 
A) tactile fremitus. 
B) crepitus. 
C) friction rub. 
D) adventitious sounds.

Question 11

During morning assessment,the nurse notes that the patient's sputum is frothy and pink.Which of the following conditions could this finding indicate?

Accepted Answer

A) Croup 
B) Tuberculosis 
C) Viral infection 
D) Pulmonary edema 
A) Croup 
B) Tuberculosis 
C) Viral infection 
D) Pulmonary edema

Question 12

The nurse is auscultating the lungs of a sleeping patient and notes short,popping,crackling sounds that stop after a few breaths.The nurse recognizes that these breath sounds are:

Accepted Answer

A) atelectatic crackles,and not pathological. 
B) fine crackles,which may be a sign of pneumonia. 
C) vesicular breath sounds. 
D) fine wheezes. 
A) atelectatic crackles,and not pathological. 
B) fine crackles,which may be a sign of pneumonia. 
C) vesicular breath sounds. 
D) fine wheezes.

Question 13

A teenage patient comes to the emergency department complaining of an inability to "breathe and a sharp pain in my left chest." 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.This description is consistent with:

Accepted Answer

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

Question 14

The most important technique when progressing from one auscultatory site on the thorax to another is:

Accepted Answer

A) side-to-side comparison. 
B) top-to-bottom comparison. 
C) posterior-to-anterior comparison. 
D) interspace-by-interspace comparison. 
A) side-to-side comparison. 
B) top-to-bottom comparison. 
C) posterior-to-anterior comparison. 
D) interspace-by-interspace comparison.

Question 15

During examination of the anterior thorax,the nurse is aware that the trachea bifurcates anteriorly at the:

Accepted Answer

A) costal angle. 
B) sternal angle. 
C) xiphoid process. 
D) suprasternal notch. 
A) costal angle. 
B) sternal angle. 
C) xiphoid process. 
D) suprasternal notch.

Question 16

A 35-year-old recent immigrant complains of having a cough,expectoration of rust-coloured sputum,low-grade afternoon fevers,and night sweats for the past 2 months.The nurse's preliminary analysis,based on this history,is that this patient may be suffering from:

Accepted Answer

A) bronchitis. 
B) pneumonia. 
C) tuberculosis. 
D) pulmonary edema. 
A) bronchitis. 
B) pneumonia. 
C) tuberculosis. 
D) pulmonary edema.

Question 17

A patient has a long history of chronic emphysema.During assessment,the nurse is most likely to observe:

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

During percussion,the nurse knows that a dull percussion note elicited over a lung lobe most likely results from:

Accepted Answer

A) shallow breathing. 
B) normal lung tissue. 
C) decreased adipose tissue. 
D) increased density of lung tissue. 
A) shallow breathing. 
B) normal lung tissue. 
C) decreased adipose tissue. 
D) increased density of lung tissue.

Question 19

A patient has been admitted to the emergency department with a medical diagnosis of possible pulmonary embolism.Which assessment findings would the nurse recognize as related to this condition?

Accepted Answer

A) Absent or decreased breath sounds 
B) Productive cough with thin,frothy sputum 
C) Chest pain that is worse on deep inspiration,dyspnea 
D) Diffuse infiltrates with areas of dullness upon percussion 
A) Absent or decreased breath sounds 
B) Productive cough with thin,frothy sputum 
C) Chest pain that is worse on deep inspiration,dyspnea 
D) Diffuse infiltrates with areas of dullness upon percussion

Question 20

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

Accepted Answer

A) consists of two lobes. 
B) is divided by a 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 a 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.

Exam 19: Thorax and Lungs

Which of the following adventitious sounds would be produced by air passing through narrowed bronchioles?

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

MATCHING The nurse is evaluating voice sounds during respiratory assessment.Match the assessment with the correct technique. -The normal response is faint,muffled,and almost inaudible when the patient says "one,two,three" in a very soft voice.

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

When auscultating the lungs of an adult patient,the nurse notes that over the posterior lower lobes,low-pitched,soft breath sounds are heard,with inspiration being longer than expiration.The nurse is aware that these are:

When assessing for tactile fremitus,over which location is it normal to feel tactile fremitus most intensely?

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

Which of the following about the vertebra prominens is true? The vertebra prominens is:

The nurse knows that expected assessment findings in the normal adult lung include:

During palpation of the anterior chest wall,the nurse notes a coarse,crackling sensation over the skin surface and suspects:

During morning assessment,the nurse notes that the patient's sputum is frothy and pink.Which of the following conditions could this finding indicate?

The nurse is auscultating the lungs of a sleeping patient and notes short,popping,crackling sounds that stop after a few breaths.The nurse recognizes that these breath sounds are:

The most important technique when progressing from one auscultatory site on the thorax to another is:

During examination of the anterior thorax,the nurse is aware that the trachea bifurcates anteriorly at the:

A 35-year-old recent immigrant complains of having a cough,expectoration of rust-coloured sputum,low-grade afternoon fevers,and night sweats for the past 2 months.The nurse's preliminary analysis,based on this history,is that this patient may be suffering from:

A patient has a long history of chronic emphysema.During assessment,the nurse is most likely to observe:

During percussion,the nurse knows that a dull percussion note elicited over a lung lobe most likely results from:

A patient has been admitted to the emergency department with a medical diagnosis of possible pulmonary embolism.Which assessment findings would the nurse recognize as related to this condition?

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

Critical Thinking and Evidence-Informed Assessment

Health Promotion in the Context of Health Assessment

Cultural Competence: Cultural Care and Social Considerations in Health Assessment

The Interview

The Complete Health History

Mental Health Assessment

Substance Use in the Context of Health Assessment

Interpersonal Violence Assessment

Assessment Techniques and the Clinical Setting

General Survey, measurement, and Vital Signs

Pain Assessment

Nutritional Assessment and Nursing Practice

Skin, hair, and Nails

Head and Neck, including Regional Lymphatic System

Eyes

Ears

Nose, mouth, and Throat

Breasts and Regional Lymphatic System

Heart and Neck Vessels

Peripheral Vascular System and Lymphatic System

Abdomen

Anus,rectum and Prostate

Musculoskeletal System

Neurological System

Male Genitourinary System

Female Genitourinary System

The Complete Health Assessment: Putting It All Together

Bedside Assessment of the Hospitalized Patient

Pregnancy

Functional Assessment of the Older Adult

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