Test Bank Chapter 26: Nursing Assessment: Respiratory System

Lewis: Medical-Surgical Nursing, 7th Edition
Test Bank
Chapter 26: Nursing Assessment: Respiratory System
MULTIPLE CHOICE
1. A patient in respiratory distress is admitted to the medical unit at the hospital. During
the initial assessment of the patient, the nurse should
a. obtain a comprehensive health history to determine the extent of any prior
respiratory problems.
b. complete a full physical examination to determine the systemic effect of the
respiratory distress.
c. delay the physical assessment and ask family members about any history of
respiratory problems.
d. perform a respiratory system assessment and ask specific questions about this
episode of respiratory distress.
Correct Answer: D
Rationale: When a patient has severe respiratory distress, only information pertinent to
the current episode is obtained, and a more thorough assessment is deferred until later.
Obtaining a comprehensive health history or full physical examination is unnecessary
until the acute distress has resolved. A focused physical assessment should be done
rapidly to help determine the cause of the distress and suggest treatment. Although family
members may know about the patients history of medical problems, the patient is the
best informant for these data.
Cognitive Level: Application
Text Reference: p. 517
Nursing Process: Assessment
NCLEX: Safe and Effective Care Environment
2. A hypothermic patient is admitted to the emergency department, and pulse oximetry
(SpO2) indicates that the O2 saturation is 95%. Which action should the nurse take
next?
a. Complete a head-to-toe assessment.
b. Place the patient on high-flow oxygen.
c. Start rewarming the patient.
d. Obtain arterial blood gases (ABG).
Correct Answer: B
Rationale: Although the O2 saturation is adequate, the left shift in the oxyhemoglobin
dissociation curve will decrease the amount of oxygen delivered to tissues, so high
oxygen concentrations should be given until the patient is normothermic. The other
actions are also appropriate, but the initial action should be to administer oxygen.
Copyright 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Test Bank
26-2
Cognitive Level: Analysis

Text Reference: pp. 513, 515

NCLEX: Physiological Integrity
3. The health care provider performs a thoracentesis on a patient with a right pleural
effusion. In preparing the patient for the procedure, the nurse positions the patient
a. supine with the head of the bed elevated 45 degrees.
b. sitting upright with the arms supported on an overbed table.
c. on the left side with the right arm extended above the head.
d. in Trendelenburgs position with both arms extended.
Correct Answer: B
Rationale: The upright position with the arms supported increases lung expansion,
allows fluid to collect at the lung bases, and expands the intercostal space so that access
to the pleural space is easier. The other positions would increase the work of breathing for
the patient and make it more difficult for the health care provider performing the
thoracentesis.
Nursing Process: Implementation

4. A patient is admitted with a metabolic acidosis of unknown origin. Based on this

diagnosis, the nurse would expect the patient to have
a. Kussmauls respirations.
b. slow, shallow respirations.
c. a low oxygen saturation (SpO2).
d. a decrease in PVO2.
Correct Answer: A
Rationale: Kussmauls (deep and rapid) respirations are a compensatory mechanism for
metabolic acidosis. Slow, shallow respirations, a low oxygen saturation rate, and a
decrease in PVO2 would not be caused by acidosis.

5. A patient who has a 30-pack-year history of smoking asks the nurse, How does
smoking really harm my lungs? The nurses response will be based on the effect of
smoking on
a. cough and gag reflexes.
b. mucociliary clearance.
c. reflex bronchoconstriction.
d. the filtration of inspired air.
Test Bank
26-3
Correct Answer: B
Rationale: Smoking decreases ciliary action and the ability of the mucociliary clearance
system to trap particles and move them out of the lung. The cough/gag reflexes, reflex
bronchoconstriction, and filtration of air by the nasal hairs are not affected by smoking.
Cognitive Level: Comprehension

6. An 80-year-old patient breathing room air has an ABG analysis. The nurse interprets
which results as normal?
a. pH 7.38, arterial carbon dioxide (PaO2) 82 mm Hg, PaCO2 40 mm Hg, and O2 sat
92%
b. pH 7.32, PaO2 85 mm Hg, PaCO2 55 mm Hg, and O2 sat 90%
c. pH 7.48, PaO2 90 mm Hg, PaCO2 31 mm Hg, and O2 sat 98%
d. pH 7.52, PaO2 91 mm Hg, PaCO2 42 mm Hg, and O2 sat 94%
Correct Answer: A
Rationale: All the values in this answer are correct. The answer beginning pH 7.32,
PaO2 85 mm Hg shows respiratory acidosis. The answer beginning pH 7.48, PaO2 90
mm Hg indicates respiratory alkalosis, and the answer beginning pH 7.52, PaO2 91 mm
Hg shows metabolic alkalosis.

7. A patient with COPD is admitted to the hospital with dyspnea and a cough producing
yellow sputum. When palpating the patients thorax, the nurse will expect to find that
chest expansion is
a. diminished.
b. asymmetric.
c. normal.
d. increased.
Correct Answer: A
Rationale: Chronic lung hyperinflation, such as occurs in COPD, decreases expansion of
the lungs with inspiration. Lung expansion is usually symmetrical with emphysema.

Test Bank
26-4
8. On auscultation of a patients lungs, the nurse hears short, high-pitched sounds just
before the end of inspiration in the right and left lower lobes. The nurse records this
finding as
a. abnormal lung sounds in the bases of both lungs.
b. inspiratory wheezes in both lungs.
c. crackles in the right and left lower lobes.
d. pleural friction rub in the right and left lower lobes.
Correct Answer: B
Rationale: Wheezes are high-pitched sounds; in this case, they are heard during the
inspiratory phase of the respiratory cycle. Abnormal breath sounds are bronchial or
bronchovesicular sounds heard in the peripheral lung fields. Crackles are low-pitched,
bubbling sounds. Pleural friction rubs are grating sounds that are usually heard during
both inspiration and expiration.

9. A patient with COPD has a barrel chest. The nurse would expect the chest x-ray
report to indicate that there is
a. overinflation of the alveoli.
b. consolidation of lung tissue.
c. fluid in the alveoli.
d. air in the pleural space.
Correct Answer: A
Rationale: A barrel chest results from lung hyperinflation and is a common finding in
patients with COPD. Consolidation, fluid, and air in the pleural space all would indicate
that intervention is needed.

10. When admitting a patient who has a pleural effusion, which technique will the nurse
use to assess for tactile fremitus?
a. Percuss over the entire posterior chest.
b. Use the fingertips to assess for vibration.
c. Place the palms of the hands on the chest wall.
d. Auscultate while the patient says ninety-nine.
Correct Answer: C
Test Bank
26-5
Rationale: To assess for tactile fremitus, the nurse should use the palms of the hands to
assess for vibration when the patient repeats a word or phrase such as 99. Percussion,
palpation with the fingertips, and auscultation are also used during the respiratory
assessment but will not assess for fremitus.

11. A patient with a chronic cough with blood-tinged sputum undergoes a bronchoscopy.
Following the bronchoscopy, the nurse should
a. check vital signs every 15 minutes for 2 hours.
b. place the patient on bed rest for at least 4 hours.
c. keep the patient NPO until the gag reflex returns.
d. elevate the head of the bed to 80 to 90 degrees.
Correct Answer: C
Rationale: Because a local anesthetic is used to suppress the gag/cough reflexes during
bronchoscopy, the nurse should monitor for the return of these reflexes before allowing
the patient to take oral fluids or food. Vital signs are monitored immediately after the
procedure but should not need to be obtained every 15 minutes for 2 hours. The patient
does not need to be on bed rest, and the head of the bed does not need to be in the highFowlers position.

12. A patient who is restricted to bed rest asks the nurse the purpose of the deep breathing
exercises. Which reply by the nurse is correct?
a. Deep breathing enhances ciliary activity and promotes bronchial clearance.
b. Deep breathing stretches the alveoli and stimulates the production of surfactant.
c. Deep breathing increases the diaphragmatic strength improving respiratory effort.
d. Deep breathing stimulates the Hering-Breuer reflex to increase respiratory rate.
Correct Answer: B
Rationale: Taking deep breaths or sighs usually occurs every five to six breaths and
(through alveolar stretching and improved surfactant production) decreases the risk for
atelectasis. Ciliary activity, diaphragmatic strength, and the respiratory rate are not
changed by deep breathing.

Test Bank
26-6
13. When auscultating a patients chest while the patient takes a deep breath, the nurse
hears loud, high-pitched, blowing sounds at both lung bases. The nurse will
document these as
a. adventitious sounds.
b. abnormal sounds.
c. vesicular sounds.
d. normal sounds.
Correct Answer: B
Rationale: The description indicates that the nurse hears bronchial breath sounds that are
abnormal when heard at the lung base. Adventitious sounds are crackles, wheezes,
rhonchi, and friction rubs. Vesicular sounds are low-pitched, soft sounds heard over all
lung areas except the major bronchi.

14. In analyzing the results of a patients blood gas analysis, the nurse will be most
concerned about an
a. arterial oxygen tension (PaO2) of 60 mm Hg.
b. arterial oxygen saturation (SaO2) of 91%.
c. arterial carbon dioxide (PaCO2) of 47 mm Hg.
d. arterial bicarbonate level (HCO3) of 27 mEq/L.
Correct Answer: A
Rationale: All the values are abnormal, but the low PaO2 indicates that the patient is at
the point on the oxyhemoglobin dissociation curve where a small change in the PaO2 will
cause a large drop in the O2 saturation and a decrease in tissue oxygenation. The nurse
should intervene immediately to improve the patients oxygenation.

15. While assessing the role-relationship health pattern in a patient with respiratory
problems, the nurse should specifically ask about
a. any history of cigarette smoking.
b. recent alterations in sexual activity.
c. the course of the patients illness.
d. work exposure to respiratory irritants.
Correct Answer: D
Test Bank
26-7
Rationale: The role-relationship pattern includes information about the occupational

exposure to fumes and allergens. History of cigarette smoking and the course of the
illness are assessed in the health perception-health management pattern. Alterations in
sexuality are assessed in the sexuality-reproductive pattern.
NCLEX: Health Promotion and Maintenance
16. While caring for a patient with respiratory disease, the nurse observes that the
patients SpO2 drops from 94% to 85% when the patient ambulates in the hall. The
nurse determines that
a. supplemental oxygen should be used whenever the patient exercises.
b. arterial blood gas analysis should be done to verify the patients SpO2.
c. the response is normal and the patient should continue at this activity level.
d. the patient activity should be limited until the disease process is resolved.
Correct Answer: A
Rationale: The drop in SpO2 to 85% indicates that the patient is hypoxemic and needs
supplemental oxygen when exercising. ABG measurements are unnecessary and would
increase patient discomfort and expense. The patient will need to continue to ambulate to
avoid the many complications of immobility.
Nursing Process: Evaluation

17. In reviewing the results of a patients pulmonary function test, the nurse recognizes
that a patient with COPD is likely to have an increased
a. forced vital capacity.
b. peak expiratory flow.
c. tidal volume.
d. residual volume.
Correct Answer: D
Rationale: Because elastic recoil of the lungs is decreased with COPD, the residual
volume is increased. Tidal volume, forced vital capacity, and peak expiratory flow rate
are likely to be decreased.

18. The nurse is observing a student who is auscultating a patients lungs. Which action
by the student indicates that the nurse should intervene?
Test Bank
a.
b.
c.
d.
26-8
The student compares breath sounds from side to side.

The student starts at the base of the posterior lung and moves to the apices.
The student places the stethoscope over the scapulae and then auscultates.
The student listens only over the posterior part of the chest.
Correct Answer: C
Rationale: The stethoscope should be placed over lung tissue, not over bony structures.
Breath sounds should be compared from side to side. The techniques of starting at the
lung base and then moving toward the apices and listening only over the posterior chest
are acceptable.

19. When assessing the respiratory system of a 78-year-old patient, which of these data
indicate that the nurse should take immediate action?
a. The chest appears barrel shaped.
b. The patient has a weak cough effort.
c. Crackles are audible in the lower two thirds of the posterior chest.
d. Hyperresonance is present across both sides of the chest.
Correct Answer: C
Rationale: Crackles in the lower two thirds of the lungs indicate that the patient may
have an acute problem such as heart failure. The nurse should immediately accomplish
further assessments, such as oxygen saturation, and notify the health care provider. A
barrel-shaped chest, hyperresonance to percussion, and a weak cough effort are
associated with aging. Further evaluation may be needed, but immediate action is not
indicated.

20. When performing an assessment of the patients respiratory system, the nurse uses the
following illustrated technique to evaluate
Test Bank
a.
b.
c.
d.
26-9
chest expansion.
tactile fremitus.
accessory muscle use.
diaphragmatic excursion.
Correct Answer: A
Rationale: When assessing chest expansion on the posterior chest, the nurse will place
the hands at the level of the 10th rib, position the thumbs until they meet over the spine,
and have the patient breathe deeply. Tactile fremitus is assessed by having the patient
repeat a word or phrase such as ninety-nine while the nurse uses the palms of the hands
to assess for vibration. Accessory muscle use and anterior-posterior diameter are assessed
during inspection of the chest and do not require palpation.

21. A patient with chronic hypoxemia (SaO2 levels of 89%-90%) caused by COPD has
just been admitted with increasing shortness of breath. In planning for discharge,
which of these actions by the nurse will be most effective in improving compliance
with discharge teaching?
a. Have the patient repeat the instructions immediately after the teaching.
b. Arrange for the patients spouse to be present during the teaching.
c. Accomplish the patient teaching just before the scheduled discharge.
d. Start giving the patient discharge teaching on the day of admission.
Correct Answer: B
Rationale: Hypoxemia interferes with the patients ability to learn and retain
information, so having the patients spouse present will increase the likelihood that
discharge instructions will be followed. Having the patient repeat the instructions will
indicate that the information is understood at the time, but it does not guarantee retention
of the information. Because the patient is likely to be distracted just before discharge,
giving discharge instructions just before discharge is not ideal. The patient is likely to be
anxious and even more hypoxemic than usual on the day of admission, so teaching about
discharge should be postponed.
Nursing Process: Planning

22. A patient is admitted to the emergency department complaining of sudden onset

shortness of breath and diagnosed with a possible pulmonary embolus. To confirm the
diagnosis, the nurse will anticipate preparing the patient for a
a. chest x-ray.
b. spiral CT scan.
Test Bank
26-10
c. bronchoscopy.
d. PET scan.
Correct Answer: B
Rationale: Spiral CT scans are the most commonly used test to diagnose pulmonary
emboli. A chest x-ray may be ordered but will not be diagnostic for a pulmonary
embolus. Bronchoscopy is used to inspect for changes in the bronchial tree, not to assess
for vascular changes. PET scans are most useful in determining the presence of
malignancy.
Nursing Process: Planning

23. The nurse is admitting a patient who has a diagnosis of an acute asthma attack. Which
information obtained by the nurse indicates that the patient may need teaching
regarding medication use?
a. The patient has been using the albuterol (Proventil) inhaler more frequently over
the last 4 days.
b. The patient became very short of breath an hour before coming to the hospital.
c. The patient has been taking acetaminophen (Tylenol) 650 mg every 6 hours for
chest-wall pain.
d. The patient says there have been no acute asthma attacks during the last year.
Correct Answer: A
Rationale: The increased need for a rapid-acting bronchodilator should alert the patient
that an acute attack may be imminent and that a change in therapy may be needed. The
patient should be taught to contact a health care provider if this occurs. The other data do
not indicate any need for additional teaching.

24. A patient is scheduled for a spiral CT scan to rule out a pulmonary embolus. Which
information obtained by the nurse is most important to communicate to the health
care provider before the examination?
a. The apical pulse is irregular.
b. The oxygen saturation is 93%.
c. The patient is allergic to shellfish.
d. The patient is very tachypneic.
Correct Answer: C
Test Bank
26-11
Rationale: Because the contrast solution is iodine-based, the patient may need to have
the CT scan without contrast or be premedicated before contrast injection. The irregular
pulse, oxygen saturation, and tachypnea all need further assessment or intervention but
are not unusual for a patient with a possible pulmonary embolus.


Test Bank Chapter 26: Nursing Assessment: Respiratory System

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Lewis: Medical-Surgical Nursing, 7th Edition

Cognitive Level: Analysis

Text Reference: pp. 513, 515

Text Reference: pp. 528, 530

4. A patient is admitted with a metabolic acidosis of unknown origin. Based on this

Text Reference: p. 524

Copyright 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Text Reference: p. 516

Text Reference: p. 514

Text Reference: pp. 524, 526

Copyright 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Text Reference: p. 525

Text Reference: pp. 511, 521

Copyright 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Text Reference: p. 522

Text Reference: p. 528

Text Reference: p. 511

Copyright 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Text Reference: p. 524

Text Reference: p. 513

Copyright 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Rationale: The role-relationship pattern includes information about the occupational

Text Reference: p. 515

Text Reference: p. 531

Copyright 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

The student compares breath sounds from side to side.

Text Reference: p. 522

Text Reference: p. 524

Copyright 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Text Reference: p. 522

Text Reference: p. 520

22. A patient is admitted to the emergency department complaining of sudden onset

Copyright 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Text Reference: p. 526

Text Reference: p. 517

Copyright 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Text Reference: p. 527

Copyright 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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