Question 1

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 2

A patient has a long history of chronic obstructive pulmonary disease.During the 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 3

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

Accepted Answer

A) seen 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) seen 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 4

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 5

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

Accepted Answer

A) the spinous process of C7.2.usually not palpable in most individuals. 
B) opposite the interior border of the scapula. 
C) located next to the manubrium of the sternum. 
A) the spinous process of C7.2.usually not palpable in most individuals. 
B) opposite the interior border of the scapula. 
C) located next to the manubrium of the sternum.

Question 6

When auscultating the chest in an adult,the nurse would:

Accepted Answer

A) instruct the patient to take deep,rapid breaths. 
B) instruct the patient to breathe in and out through his or her nose. 
C) use the diaphragm of the stethoscope held firmly against the chest. 
D) use the bell of the stethoscope held lightly against the chest to avoid friction. 
A) instruct the patient to take deep,rapid breaths. 
B) instruct the patient to breathe in and out through his or her nose. 
C) use the diaphragm of the stethoscope held firmly against the chest. 
D) use the bell of the stethoscope held lightly against the chest to avoid friction.

Question 7

During an examination of the anterior thorax,the nurse recalls 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 8

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.

Question 9

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 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

A teenage patient comes to the emergency department with complaints of an inability to "breathe and a sharp pain in my left chest." The assessment findings include the following: 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 asthmatic attack. 
A) bronchitis. 
B) a pneumothorax. 
C) acute pneumonia. 
D) an asthmatic attack.

Question 11

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 12

Air passing through narrowed bronchioles would produce which of the following 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 13

When inspecting the anterior chest of an adult,the nurse should assess for:

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 14

A 35-year-old recent immigrant is being seen in the clinic for complaints of a cough that is associated with rust-colored 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 15

When assessing tactile fremitus,the nurse recalls that it is normal to feel tactile fremitus most intensely over which location?

Accepted Answer

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

Question 16

A 70-year-old patient is being seen in the clinic for severe exacerbation of his heart failure.Which of the following 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 
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 17

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

Accepted Answer

A) atalectatic crackles,and not pathologic. 
B) fine crackles and they may be a sign of pneumonia. 
C) vesicular breath sounds. 
D) fine wheezes. 
A) atalectatic crackles,and not pathologic. 
B) fine crackles and they may be a sign of pneumonia. 
C) vesicular breath sounds. 
D) fine wheezes.

Question 18

MATCHING
The nurse is assessing voice sounds during a respiratory assessment.Match the assessment with the correct technique:

-B = Bronchophony

Accepted Answer

A) The normal response is faint,muffled,and almost inaudible when the patient says "one,two,three" in a very soft voice. 
B) Ask the person to say "ninety-nine" repeatedly while auscultating the chest wall.Normally,a sound will be heard but the examiner will not be able to distinguish exactly what is being said. 
C) Listen to the chest while the patient says a long "ee-ee-ee" sound;hearing a long "aaaaaa" sound may be noted over areas of consolidation. 
A) The normal response is faint,muffled,and almost inaudible when the patient says "one,two,three" in a very soft voice. 
B) Ask the person to say "ninety-nine" repeatedly while auscultating the chest wall.Normally,a sound will be heard but the examiner will not be able to distinguish exactly what is being said. 
C) Listen to the chest while the patient says a long "ee-ee-ee" sound;hearing a long "aaaaaa" sound may be noted over areas of consolidation.

Question 19

Which of the following 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,decreasing 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,decreasing their ability to collapse and recoil.

Exam 18: Thorax and Lungs

The nurse knows that percussion over an area of atelectasis in the lungs would reveal:

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

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

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

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

When auscultating the chest in an adult,the nurse would:

During an examination of the anterior thorax,the nurse recalls that the trachea bifurcates anteriorly at the:

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

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

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

Air passing through narrowed bronchioles would produce which of the following adventitious sounds?

When inspecting the anterior chest of an adult,the nurse should assess for:

A 35-year-old recent immigrant is being seen in the clinic for complaints of a cough that is associated with rust-colored 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:

When assessing tactile fremitus,the nurse recalls that it is normal to feel tactile fremitus most intensely over which location?

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

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

MATCHING The nurse is assessing voice sounds during a respiratory assessment.Match the assessment with the correct technique: -B = Bronchophony

Which of the following describes normal changes in the respiratory system of the older adult?

Critical Thinking in Health Assessment

Developmental Tasks and Health Promotion Across the Life Cycle

Cultural Competence: Cultural Care

The Interview

The Complete Health History

Mental Status 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

Reassessment of the Hospitalized Adult

The Pregnant Female

Functional Assessment of the Older Adult

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