Question 1

The primary respiratory muscles engaged in normal inspiration include the:

Accepted Answer

A) Diaphragm and intercostals. 
B) Sternomastoid and scalene. 
C) Trapezius and rectus abdominis. 
D) External obliques and pectoralis major. 
A) Diaphragm and intercostals. 
B) Sternomastoid and scalene. 
C) Trapezius and rectus abdominis. 
D) External obliques and pectoralis major. A

Question 2

During an assessment of an adult, the nurse has noted unequal chest expansion and recognizes that this occurs in which situation?

Accepted Answer

A) In an obese patient 
B) When part of the lung is obstructed or collapsed 
C) When bulging of the intercostal spaces is present 
D) When accessory muscles are used to augment respiratory effort 
A) In an obese patient 
B) When part of the lung is obstructed or collapsed 
C) When bulging of the intercostal spaces is present 
D) When accessory muscles are used to augment respiratory effort B

Question 3

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

Accepted Answer

A) Increased thoracic expansion. 
B) Decreased mobility of the thorax. 
C) Decreased anteroposterior diameter. 
D) Bronchovesicular breath sounds throughout the lungs. 
A) Increased thoracic expansion. 
B) Decreased mobility of the thorax. 
C) Decreased anteroposterior diameter. 
D) Bronchovesicular breath sounds throughout the lungs. B

Question 4

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 5

During assessment of the patient's posterior chest for lung sounds, the nurse will auscultate the right lung for the:

Accepted Answer

A) Apex of the lung. 
B) Upper and lower lobes. 
C) Lower lobe, because the upper lobe is too small. 
D) Upper, middle, and lower lobes. 
A) Apex of the lung. 
B) Upper and lower lobes. 
C) Lower lobe, because the upper lobe is too small. 
D) Upper, middle, and lower lobes.

Question 6

When assessing tactile fremitus, the nurse normally feel tactile fremitus most intensely:

Accepted Answer

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

Question 7

When performing a respiratory assessment on a patient, the nurse notes a costal angle of approximately 90 degrees.This characteristic is:

Accepted Answer

A) Observed in patients with kyphosis. 
B) Indicative of pectus excavatum. 
C) A normal finding in a healthy adult. 
D) An expected finding in a patient with a barrel chest. 
A) Observed in patients with kyphosis. 
B) Indicative of pectus excavatum. 
C) A normal finding in a healthy adult. 
D) An expected finding in a patient with a barrel chest.

Question 8

The nurse is reviewing the characteristics of breath sounds.Which statement about bronchovesicular breath sounds is true? Bronchovesicular breath sounds are:

Accepted Answer

A) Musical in quality. 
B) Usually caused by a pathological condition. 
C) Expected near the major airways. 
D) Similar to bronchial sounds except shorter in duration. 
A) Musical in quality. 
B) Usually caused by a pathological condition. 
C) Expected near the major airways. 
D) Similar to bronchial sounds except shorter in duration.

Question 9

The nurse is assessing voice sounds during a respiratory assessment.Which of these findings indicates a normal assessment? (Select all that apply.)

Accepted Answer

A) Voice sounds are faint, muffled, and almost inaudible when the patient whispers "one, two, three" in a very soft voice. 
B) As the patient repeatedly says "ninety-nine," the examiner clearly hears the words "ninety-nine." 
C) When the patient speaks in a normal voice, the examiner can hear a sound but cannot exactly distinguish what is being said. 
D) As the patient says a long "ee-ee-ee" sound, the examiner also hears a long "ee-ee-ee" sound. 
E) As the patient says a long "ee-ee-ee" sound, the examiner hears a long "aaaaaa" sound. 
A) Voice sounds are faint, muffled, and almost inaudible when the patient whispers "one, two, three" in a very soft voice. 
B) As the patient repeatedly says "ninety-nine," the examiner clearly hears the words "ninety-nine." 
C) When the patient speaks in a normal voice, the examiner can hear a sound but cannot exactly distinguish what is being said. 
D) As the patient says a long "ee-ee-ee" sound, the examiner also hears a long "ee-ee-ee" sound. 
E) As the patient says a long "ee-ee-ee" sound, the examiner hears a long "aaaaaa" sound.

Question 10

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 patient?

Accepted Answer

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

Question 11

During an assessment, the nurse knows that expected assessment findings in the normal adult lung include the presence of:

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 hyper-resonant 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 hyper-resonant percussion tones.

Question 12

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 increased awareness of the need to breathe 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 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 increased awareness of the need to breathe 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 13

During a morning assessment, the nurse notices that the patient's sputum is frothy and pink.Which condition 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 14

A mother brings her 3-month-old infant to the clinic for evaluation of a cold.She tells the nurse that he has had "a runny nose for a week." When performing the physical assessment, the nurse notes that the child has nasal flaring and sternal and intercostal retractions.The nurse's next action should be to:

Accepted Answer

A) Assure the mother that these signs are normal symptoms of a cold. 
B) Recognize that these are serious signs, and contact the physician. 
C) Ask the mother if the infant has had trouble with feedings. 
D) Perform a complete cardiac assessment because these signs are probably indicative of early heart failure. 
A) Assure the mother that these signs are normal symptoms of a cold. 
B) Recognize that these are serious signs, and contact the physician. 
C) Ask the mother if the infant has had trouble with feedings. 
D) Perform a complete cardiac assessment because these signs are probably indicative of early heart failure.

Question 15

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 will reveal:

Accepted Answer

A) Dullness. 
B) Tympany. 
C) Resonance. 
D) Hyper-resonance. 
A) Dullness. 
B) Tympany. 
C) Resonance. 
D) Hyper-resonance.

Question 16

A 20-year-old tall, slim male 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, hyper-resonance 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) Pneumothorax. 
C) Acute pneumonia. 
D) Asthmatic attack. 
A) Bronchitis. 
B) Pneumothorax. 
C) Acute pneumonia. 
D) Asthmatic attack.

Question 17

A patient has been admitted to the emergency department with a possible medical diagnosis of pulmonary embolism.The nurse expects to see which assessment findings 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 and 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 and dyspnea 
D) Diffuse infiltrates with areas of dullness upon percussion

Question 18

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) Presence of bronchovesicular breath sounds in the peripheral lung fields 
D) 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) Presence of bronchovesicular breath sounds in the peripheral lung fields 
D) Irregular respiratory pattern and a respiratory rate of 40 breaths per minute at rest

Question 19

The nurse is listening to the breath sounds of a patient with severe asthma.Air passing through narrowed bronchioles would produce which of these adventitious sounds?

Accepted Answer

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

Question 20

The nurse is assessing the lungs of an 85-year-old patient who states having a decreased tolerance for activity.The nurse informs the patient that this results from some of the normal changes that occur in the respiratory system of the older adult:

Accepted Answer

A) Chest expansion increases with asymmetry. 
B) Respiratory muscle strength increases to compensate for a decreased vital capacity. 
C) A decrease in small airway closure occurs, leading to problems with atelectasis. 
D) Lungs are less elastic and distensible, and this decreases their ability to collapse and recoil. 
A) Chest expansion increases with asymmetry. 
B) Respiratory muscle strength increases to compensate for a decreased vital capacity. 
C) A decrease in small airway closure occurs, leading to problems with atelectasis. 
D) Lungs are less elastic and distensible, and this decreases their ability to collapse and recoil.

Exam 19: Thorax and Lungs

The primary respiratory muscles engaged in normal inspiration include the:

During an assessment of an adult, the nurse has noted unequal chest expansion and recognizes that this occurs in which situation?

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

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?

During assessment of the patient's posterior chest for lung sounds, the nurse will auscultate the right lung for the:

When assessing tactile fremitus, the nurse normally feel tactile fremitus most intensely:

When performing a respiratory assessment on a patient, the nurse notes a costal angle of approximately 90 degrees.This characteristic is:

The nurse is reviewing the characteristics of breath sounds.Which statement about bronchovesicular breath sounds is true? Bronchovesicular breath sounds are:

The nurse is assessing voice sounds during a respiratory assessment.Which of these findings indicates a normal assessment? (Select all that apply.)

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 patient?

During an assessment, the nurse knows that expected assessment findings in the normal adult lung include the presence of:

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?

During a morning assessment, the nurse notices that the patient's sputum is frothy and pink.Which condition could this finding indicate?

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 will reveal:

A patient has been admitted to the emergency department with a possible medical diagnosis of pulmonary embolism.The nurse expects to see which assessment findings related to this condition?

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

The nurse is listening to the breath sounds of a patient with severe asthma.Air passing through narrowed bronchioles would produce which of these adventitious sounds?

The nurse is assessing the lungs of an 85-year-old patient who states having a decreased tolerance for activity.The nurse informs the patient that this results from some of the normal changes that occur in the respiratory system of the older adult:

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