Health Assessment: Chapter 11 - Lungs and Respiratory System

A nurse suspects a viral infection or upper respiratory allergies when the patient describes the sputum as being which color? a. White b. Clear c. Yellow d. Pink tinged

b. Clear

On examination, a nurse finds the patient has a productive cough with green sputum and inspiratory crackles. What other findings does this nurse expect during the examination? Select all that apply. a. Dull tones to percussion b. Increased vibration on vocal fremitus c. Fever d. Decreased diaphragmatic excursion e. A sharp, abrupt pain reported when patient breathes deeply f. Muffled sounds heard when the patient says "e-e-e"

A, B, C, E

What are the functions of the upper airways? Select all that apply. a. Conduct air to lower airway. b. Provide area for gas exchange. c. Prevent foreign matter from entering respiratory system. d. Warm, humidify, and filter air entering lungs. e. Provide transportation of oxygen and carbon dioxide between alveoli and cells.

A, C, D

A nurse is assessing the respiratory system of a healthy adult. Which findings does this nurse expect to find? Select all that apply. a. Thoracic expansion that is symmetric bilaterally b. Respiratory rate of 24 breaths/min c. Bronchophony revealing clear voice sounds d. Breath sounds clear with vesicular breath sounds heard over most lung fields e. Anteroposterior diameter of the chest about a 1:2 ratio of anteroposterior to lateral diameter f. Symmetric thorax with ribs sloping downward at about 45 degrees relative to the spine

A, D, E, F

Which finding may indicate abnormal thoracic expansion? a. A 4-cm diaphragmatic excursion b. A 1:2 anteroposterior to lateral diameter c. An S-shaped curvature of the spine d. A costal angle of 85 degrees

c. An S-shaped curvature of the spine

On inspection, a nurse finds the patient's anteroposterior diameter of the chest to be the same as the lateral diameter. Based on this finding, what additional data does the nurse anticipate? a. Increased vocal fremitus on palpation b. Dull tones heard on percussion c. Decreased breath sounds on auscultation d. Complaint of sharp chest pain on inspiration

c. Decreased breath sounds on auscultation

A patient has an infection of the terminal bronchioles and alveoli that involves the right lower lobe of the lung. Which abnormal finding are expected? a. Dyspnea with diminished breath sounds bilaterally b. Asymmetric chest expansion on the right side c. Fever and tachypnea with crackles over the right lower lobe d. Prolonged expiration with an occasional wheeze in the right lower lobe

c. Fever and tachypnea with crackles over the right lower lobe

During inspection of the respiratory system the nurse documents which finding as abnormal? a. Skin color consistent with patient's ethnicity b. 1:2 ratio of anteroposterior to lateral diameter c. Anterior costal angle is 85 degrees d. Patient leaning forward with arms braced against knees

d. Patient leaning forward with arms braced against knees

A patient has right lower lobe pneumonia, creating a consolidation in that lung. In assessing for vocal fremitus, the nurse found increased fremitus over the right lower lung. What finding does the nurse anticipate when assessing vocal resonance to confirm the consolidation? a. Bronchophony reveals the patient's spoken "99" as clear and loud. b. No sounds are expected since sounds cannot be transmitted through consolidation. c. Egophony reveals indistinguishable sounds when the patient says "e-e-e." d. Whispered pectoriloquy reveals a muffled sound when the patient says "1-2-3."

a. Bronchophony reveals the patient's spoken "99" as clear and loud.

Narrowing of the bronchi creates which adventitious sound? a. Wheeze b. Crackles c. Rhonchi d. Pleural friction rub

a. Wheeze

A patient tells the nurse that he has smoked 1 1/2 packs of cigarettes a day for 14 years. The nurse records this as _____ pack-years?

21

A patient is admitted to the emergency department with a tracheal obstruction. What sound does the nurse expect to hear as this patient breathes? a. Dull sounds on percussion b. Soft, muffled rhonchi heard over the trachea c. Bubbling or rasping sounds heard over the trachea d. High-pitched sounds on inspiration and exhalation

d. High-pitched sounds on inspiration and exhalation

Where does a nurse expect to hear bronchovesicular lung sounds in a healthy adult? a. In the lower lobes b. Over the trachea c. In the apices of the lungs d. Near the sternal border

d. Near the sternal border

How does the nurse palpate the chest for tenderness, bulges, and symmetry? a. Uses the fist of the dominant hand to gently tap the anterior, lateral, and posterior chest, comparing one side with another b. Uses the ulnar surface of one hand to palpate the anterior, posterior, and lateral chest, comparing one side with another c. With the tips of the fingers, palpates the skin over the chest and the alignment of the vertebrae d. With the palmar surface of fingers of both hands, feel the consistency of the skin over the chest and the alignment of vertebrae

d. With the palmar surface of fingers of both hands, feel the consistency of the skin over the chest and the alignment of vertebrae

On inspection, the nurse finds the patient's anteroposterior diameter of the chest to be the same as the lateral diameter. What other findings does this nurse expect during the examination? Select all that apply. a. Inspiratory wheezing found on auscultation b. Hyperresonance heard on percussion c. Decreased breath sounds heard on auscultation d. Deceased diaphragmatic excursion on percussion e. A sharp, abrupt pain reported when the patient breathes deeply f. Decreased to absent vibration on vocal fremitus

B, C, D, F

During the problem-based history, a patient reports coughing up sputum when lying on the right side, but not when lying on the back or left side. The nurse suspects this patient may have a lung abscess. What additional question does the nurse ask to gather more data? a. "Does the sputum have an odor?" b. "Do you have chest pain when you take a deep breath?" c. "Have you also experienced tightness in your chest?" d. "Have you coughed up any blood?"

a. "Does the sputum have an odor?"

After taking a brief health history, a nurse needs to complete a focused assessment on which patient? a. A male who works as a painter b. A male who plays basketball and hockey c. A female who recently moved into a college dormitory d. A female who has a history of gout

a. A male who works as a painter

Which finding does the nurse expect when performing tactile fremitis? a. A vibration of sounds that are equal bilaterally b. A change in muscle tone when the patient inhales and exhales, indicating weakness c. The symmetric rise of the thorax as the patient speaks, indicating equal expansion d. Coughing triggered by patient speech, indicating bronchial irritation

a. A vibration of sounds that are equal bilaterally

A nurse notices a patient's chest wall moving in during inspiration and out during expiration. What additional assessment must the nurse perform immediately? a. Palpate for tracheal deviation. b. Auscultate for bronchovesicular breath sounds in the lung periphery. c. Palpate posterior thoracic muscles for tenderness. d. Auscultate for absence of breath sounds in the lung periphery.

a. Palpate for tracheal deviation.

On auscultation of a patient's lungs, the nurse hears a low-pitched, coarse, loud, and low snoring sound. Which term does the nurse use to document this finding? a. Rhonchi b. Wheeze c. Crackles d. Pleural friction rub

a. Rhonchi

Which patient should the nurse assess first? a. The patient whose respiratory rate is 26 breaths per minute and whose trachea deviates to the right. b. The patient who has pleuritic chest pain, bilateral crackles, a productive cough of yellow sputum, and fever. c. The patient who is short of breath, using pursed-lip breathing, and in a tripod position. d. The patient whose respiratory rate is 20 breaths/min, and has 8-word dyspnea and expiratory wheezes.

a. The patient whose respiratory rate is 26 breaths per minute and whose trachea deviates to the right.

Which breath sounds are expected over the posterior chest of an adult? a. Vesicular b. Bronchovesicular c. Bronchial d. Bronchoalveolar

a. Vesicular

A nurse had previously heard crackles over both lungs of a patient. As the patient improves, what lung sounds does the nurse expect to hear in the patient's lungs? a. Vesicular breath sounds heard in peripheral lung fields b. Bronchial breath sounds heard over the bronchi c. Bronchovesicular breath sounds heard over the apices d. Rhonchi heard over the main bronchi

a. Vesicular breath sounds heard in peripheral lung fields

Which question will give the nurse additional information about the nature of a patient's dyspnea? a. "How often do you see the physician?" b. "How has this condition affected your day-to-day activities?" c. "Do you have a cough that occurs with the dyspnea?" d. "Does your heart rate increase when you are short of breath?"

b. "How has this condition affected your day-to-day activities?"

A nurse auscultates low-pitched, coarse snoring sounds in a patient's lungs during inhalation. What is the most appropriate action for the nurse to take at this time? a. Palpate the posterior thorax for vocal fremitus. b. Ask the patient to cough and repeat auscultation. c. Auscultate the posterior thorax for vocal sounds. d. Percuss the posterior thorax for tone.

b. Ask the patient to cough and repeat auscultation.

The nurse is comparing pitch and duration of the various types of a patient's breath sounds and recognizes which one of these as an expected finding? a. Bronchial sounds are low-pitched and have a 2:1 inspiratory-versus-expiratory ratio. b. Bronchovesicular sounds have a moderate pitch and 1:1 expiratory-versus-inspiratory ratio. c. Vesicular breath sounds are high-pitched and have a 1:2 inspiratory-versus-expiratory ratio. d. Wheezes are low-pitched and have a 2.5:1 inspiratory-versus-expiratory ratio.

b. Bronchovesicular sounds have a moderate pitch and 1:1 expiratory-versus-inspiratory ratio.

A nurse is assessing a patient who was diagnosed with emphysema and chronic bronchitis 5 years ago. During the assessment of this patient's integumentary system, what finding should the nurse correlate to this respiratory disease? a. Dry, flaky skin b. Clubbing of the fingers c. Hypertrophy of the nails d. Hair loss from the scalp

b. Clubbing of the fingers

A nurse is auscultating the lungs of a healthy male patient and hears crackles on inspiration. What action can the nurse take to ensure this is an accurate finding? a. Make sure the bell of the stethoscope is used, rather than the diaphragm. b. Hold stethoscope firmly to prevent movement when placed over chest hair. c. Ask the patient not to talk while the nurse is listening to the lungs. d. Change the patient's position to ensure accurate sounds.

b. Hold stethoscope firmly to prevent movement when placed over chest hair.

A patient reports a productive cough with yellow sputum, fever, and a sharp pain when taking a deep breath to cough. Based on these data, what abnormal finding will the nurse anticipate on examination? a. Decreased breath sounds on auscultation b. Increased tactile fremitus and dull percussion tones c. Inspiratory wheezing found on auscultation d. Muffled sounds heard when the patient says "e-e-e"

b. Increased tactile fremitus and dull percussion tones

A nurse suspects a patient has a chest wall injury and wants to collect more data about thoracic expansion. Which is the appropriate technique to use? a. Place the palmar side of each hand against the lateral thorax at the level of the waist, ask the patient to take a deep breath, and observe lateral movement of the hands. b. Place both thumbs on either side of the patient's T9 to T10 spinal processes, extend fingers laterally, ask the patient to take a deep breath, and observe lateral movement of the thumbs. c. Place both thumbs on either side of the patient's T7 to T8 spinal processes, extend fingers laterally, ask the patient to exhale deeply, and observe lateral inward movement of the thumbs. d. Place the palmar side of each hand on the shoulders of the patient, ask the patient to sit up straight and take a deep breath, and observe symmetric movement of the shoulders.

b. Place both thumbs on either side of the patient's T9 to T10 spinal processes, extend fingers laterally, ask the patient to take a deep breath, and observe lateral movement of the thumbs.

A patient is suspected of having a lung consolidation. A nurse uses the three techniques for assessing vocal resonance in this patient. What is the expected finding among the three procedures that will help eliminate consolidation as a problem? a. The nurse documents clearly hearing the patient say "99." b. The nurse documents hearing muffled sounds when the patient says "1-2-3." c. The nurse documents hearing no sounds when the patient says "e-e-e." d. The nurse documents clearly hearing the patient say "a-a-a."

b. The nurse documents hearing muffled sounds when the patient says "1-2-3."

Which question gives the nurse further information about the patient's complaint of chest pain? a. "Have you had your influenza immunization this year?" b. "Are there environmental conditions that may affect your breathing at home?" c. "How would you describe the chest pain?" d. "Has the chest pain been interrupting your sleep?"

c. "How would you describe the chest pain?"

A patient tells the nurse that she has smoked two packs of cigarettes a day for 20 years. The nurse records this as how many pack-years? a. 10 b. 20 c. 40 d. 60

c. 40

A nurse examines a patient with a pleural effusion and finds decreased fremitus. What additional abnormal finding should the nurse anticipate during further examination? a. An increase in the anteroposterior to lateral ratio b. Hyperresonance over the affected area c. Absent breath sounds in the affected area d. Increased vocal fremitus over the affected area

c. Absent breath sounds in the affected area

A patient complains of shortness of breath and having to sleep on three pillows to breathe comfortably at night. During the nurse's examination, what findings will suggest that the cause of this patient's dyspnea is due to heart disease rather than respiratory disease? a. Increased anteroposterior diameter b. Clubbing of the fingers c. Bilateral peripheral edema d. Increased tactile fremitus

c. Bilateral peripheral edema

A nurse palpating the chest of a patient finds increased fremitus bilaterally. What is the significance of this finding? a. An expected finding b. Chronic obstructive pulmonary disease c. Bilateral pneumonia d. Bilateral pneumothorax

c. Bilateral pneumonia

A nurse inspects a patient's hands and notices clubbing of the fingers. The nurse correlates this finding with what condition? a. Pulmonary infection b. Trauma to the thorax c. Chronic hypoxemia d. Allergic reaction

c. Chronic hypoxemia

In reviewing the patient's record, the nurse notes that the patient has air in the subcutaneous tissue. The nurse validates that this patient has crepitus with which finding? a. Asymmetric expansion of the chest wall on inhalation b. Increased transmission of vocal vibrations on auscultation c. Crackling sensation under the skin of the chest on palpation d. Coarse grating sounds heard over the mediastinum on inspiration

c. Crackling sensation under the skin of the chest on palpation

A nurse is assessing for vocal (tactile) fremitus on a patient with pulmonary edema. Which is the appropriate technique to use? a. Systematically percuss the posterior chest wall following the same pattern that is used for auscultation and listen for a change in tone from resonant to dull. b. Place the pads of the fingers on the right and left thoraces and palpate the texture and consistency of the skin feeling for a crackly sensation under the fingers. c. Place the palms of the hands on the right and left thoraces, ask the patient to say "99," and feel for vibrations. d. Place both thumbs on either side of the patient's spinal processes, extend fingers laterally, ask the patient to take a deep breath, and feel for vibrations.

c. Place the palms of the hands on the right and left thoraces, ask the patient to say "99," and feel for vibrations.

During a history, a nurse notices a patient is short of breath, is using pursed-lip breathing, and maintains a tripod position. Based on these data, what abnormal finding should the nurse expect to find during the examination? a. Increased tactile fremitus b. Inspiratory and expiratory wheezing c. Tracheal deviation d. An increased anteroposterior diameter

d. An increased anteroposterior diameter

During a symptom analysis, a patient describes his productive cough and states his sputum is thick and yellow. Based on these data, the nurse suspects which factor as the cause of these symptoms? a. Virus b. Allergy c. Fungus d. Bacteria

d. Bacteria

A nurse in the emergency department is assessing a patient with a moderate left pneumothorax. What does this nurse expect to find during the respiratory examination? a. Increased fremitus over the left chest b. Tracheal deviation to the left side c. Hyporesonant percussion tones over the left chest d. Distant to absent breath sounds over the left chest

d. Distant to absent breath sounds over the left chest