NCLEX Lung Assessment
A nurse cares for a client admitted after falling off a ladder onto a concrete floor. The client is not arousable and pupils are fixed and dilated. When performing a respiratory assessment, the nurse recognizes which breathing pattern as normal for clients with brain damage? a) Biot's b) Cheyne-Stokes c) Kussmaul's d) Retractive
A)Biot's
The apex of each lung is located at the a) level of the sixth rib. b) area slightly above the clavicle. c) left oblique fissure. d) level of the diaphragm.
B)area slightly above the clavicle.
The nurse is reviewing the client's health history and notes he has pectus excavatum. The nurse would assess the client for what? a) Pectoriloquy b) Pigeon chest c) Funnel chest d) Intercostal bulging
C)Funnel chest
Which of the following muscles is primarily responsible for thoracic cavity enlargement? a) Sternomastoid b) Parasternal c) Scalene d) Diaphragm
D)Diaphragm
Upon inspection of a client's chest, a nurse observes an increase in the anterior posterior diameter. The nurse recognizes this as a finding in which disease process? a) Chronic obstructive pulmonary disease b) Pneumothorax c) Carcinoma of the lungs d) Tuberculosis
A)Chronic Obstructive Pulmonary Disease
The client has been admitted through the emergency department with chronic bronchitis, has elevated CO2 levels, and has been placed on O2. What priority assessment would the nurse include? a) Evaluate changes in respiratory pattern and rate. b) Review blood work including RBC and WBC. c) Assess for signs of nonproductive cough. d) Assess the characteristics of sputum
A)Evaluate changes in respiratory pattern and rate
What would the nurse expect to hear when auscultating the lungs of a client with pleuritis? a) Friction rub b) Stridor c) Sibilant wheeze d) Decreased breath sounds
A)Friction rub
A nurse auscultates a client's lungs and hears fine crackles. What is an appropriate action by the nurse? a) Instruct the client to cough forcefully b) Listen again with the bell of the stethoscope c) Have the client breathe through the mouth d) Assess for the use of accessory muscles
A)Instruct the client to cough forcefully
A client presents to the health care clinic and reports a recent onset of a persistent cough. The client denies any shortness of breath, change in activity level, or other findings of an acute upper respiratory tract illness. What question by the nurse is most appropriate to further assess the cause for the cough? a) "Have you changed your diet within the past few weeks?" b) "How much do you exercise during the week?" c) "Do you feel that you are under a great deal of stress?' d) "Are you taking any medications on a regular basis?"
D)"Are you taking any medications on a regular basis?"
The client has been admitted through the emergency department with chronic bronchitis, has elevated CO2 levels, and has been placed on O2. What priority assessment would the nurse include? a) Assess the characteristics of sputum. b) Review blood work including RBC and WBC. c) Assess for signs of nonproductive cough. d) Evaluate changes in respiratory pattern and rate.
D)Evaluate changes in respiratory pattern and rate.
The thin double-layered serous membrane that lines the chest cavity is termed a) parietal pleura. b) visceral pleura. c) thoracic pleura. d) pulmonary pleura.
a)parietal pleura
A nurse is receiving report from the night shift about four clients. Which client would the nurse see first? a) A 64-year-old man with COPD who is short of breath and has a respiratory rate of 32 breaths/min b) A 57-year-old woman who had surgery yesterday for a small bowel obstruction with possible wound dehiscence c) A 29-year-old woman with a history of drug abuse and a heart rate of 124 beats/min d) A 23-year-old woman who had a mountain biking accident in which she suffered a neck fracture and now has numbness and tingling in her right arm
A)A 64-year-old man with COPD who is short of breath and has a respiratory rate of 32 breaths/min
A nurse observes a client sitting in the tripod position. What is an appropriate action by the nurse in response to this observation? a) Percuss to determine diaphragmatic excursion b) Observe for the use of accessory muscles c) Auscultate for the presence of crackles d) Palpate for tactile fremitus
B)Observe for the use of accessory muscles
Which of the following occurs in respiratory distress? a) Neck muscles are relaxed. b) Skin between the ribs moves inward with inspiration. c) The client speaks in sentences of 10-20 words. d) Client torso leans posteriorly.
B)Skin between the ribs moved inward with inspiration
The nurse is reviewing the client's health history and notes he has pectus excavatum. The nurse would assess the client for what? a) Pigeon chest b) Pectoriloquy c) Intercostal bulging d) Funnel chest
D)Funnel Chest
Auscultation of a 23-year-old client's lungs reveals an audible wheeze. What pathological phenomenon underlies wheezing? a) Narrowing or partial obstruction of an airway passage b) Fluid in the alveoli c) Decreased compliance of the lungs d) Blockage of a respiratory passage
a) narrowing or partial obstruction of an airway passage
A client from a severe motor vehicle accident arrives in the emergency department. The nurse observes irregular respirations of varying depth and rate followed by periods of apnea. Which of the following would the nurse suspect? a) Severe brain damage b) Diabetic ketoacidosis c) Narcotic overdose d) Renal failure
A)Severe brain damage
A high-pitched crowing sound from the upper airway results from tracheal or laryngeal spasm and is called what? a) Stridor b) Rales c) Wheezes d) Crackles
A)Stridor
The staff educator from the hospital's respiratory unit is providing a public educational event. The educator is talking about health promotion activities for people with respiratory diseases or those who are at high risk for respiratory complications. What would the educator include in the presentation? a) Teaching strategies to reduce complications of existing diagnoses b) Encouraging adequate rest c) Showing participants how to diagnose respiratory problems d) Reinforcing the need for a high-calorie diet
A)Teaching strategies to reduce complications of existing diagnoses
The lining of the trachea and bronchi, which serves to remove dust, foreign bodies, and bacteria, is termed the a) cilia. b) alveolar sacs. c) bronchioles. d) alveolar ducts.
A)cilia
A nurse performs a respiratory assessment on a client and notes the respiratory rate to be 8 breaths per minute. The nurse knows the proper term for this rate is what? a) Tachypnea b) Bradypnea c) Hypoventilation d) Hyperventilation
B)Bradypnea
When performing a physical examination for a client with scoliosis, which physical characteristic should the nurse expect to find during the assessment? a) Exaggerated curvature of the thoracic vertebrae b) Lateral deviation of the spinous processes c) Shoulders and scapulae at a horizontal position d) Non-protruding, symmetrical scapulae
B)Lateral deviation of the spinous processes
A client presents to the health care facility with sudden onset of shortness of breath, inability to lie flat, and a deep, wet cough. A nurse observes a respiratory rate of 18 breaths per minute, use of accessory muscles to breathe, and inability to cough up secretions. Which nursing diagnosis can be confirmed with this data? a) Impaired Gas Exchange b) Ineffective Airway Clearance c) Ineffective Breathing Pattern d) Risk for Respiratory Infection
B)Ineffective Airway Clearance
An elderly client reports a feeling of dyspnea with normal activities of daily living. What is an appropriate action by the nurse? a) Report this to the health care provider immediately b) Observe the client's respiratory rate and pattern c) Ask the client how long they have to rest between activities d) Assess for symmetry of chest expansion
B)Observe the client' respiratory rate and pattern
An elderly client reports a feeling of dyspnea with normal activities of daily living. What is an appropriate action by the nurse? a) Ask the client how long they have to rest between activities b) Observe the client's respiratory rate and pattern c) Assess for symmetry of chest expansion d) Report this to the health care provider immediately
B)Observe the client's respiratory rate and pattern
Which action by a nurse demonstrates proper technique for assessment of chest expansion? a) Beginning at the scapular line, percuss the intercostal spaces along both sides of the posterior chest b) Place both hands on the posterior chest at T9, press thumbs together, and then ask client to take a deep breath c) Place the stethoscope on the posterior chest wall, ask the client to take a deep breath, and observe chest rise and fall d) Use the ball of both hands to feel for vibrations in a symmetrical pattern across the posterior chest
B)Place both hands on the posterior chest at T9, press thumbs together, and then ask client to take a deep breath
When percussing the anterior chest for tone, a nurse should anticipate what tone over the majority of the lung fields? a) Tympany b) Hyperresonance c) Resonance d) Dullness
C) Resonance
A client reports sharp and stabbing chest pain that worsens with deep breathing and coughing. A cardiac cause to this pain is ruled out. The description of the pain is consistent with what respiratory condition? a) Asthma b) Pneumonia c) Pleurisy d) Rales
C) pleurisy
A nurse is interviewing a client who complains of dyspnea of sudden onset. Based on this finding, the nurse should suspect which of the following causes? a) Sleep apnea b) Emphysema c) Bacterial infection d) Lung cancer
C)Bacterial Infection
A grandmother brings her 13-year-old grandson for evaluation. She noticed last week when he took off his shirt that his breastbone seemed collapsed. He seems embarrassed and says that it has been that way for awhile. He states he has no symptoms from it and that he just tries not to take off his shirt in front of anyone. He denies any shortness of breath, chest pain, or lightheadedness on exertion. His past medical history is unremarkable. He is in sixth grade and just moved in with his grandmother after his father was transferred for a work contract. His mother died several years ago in a car accident. He states that he does not smoke and has never touched alcohol. Examination shows a teenage boy appearing his stated age. Visual examination of his chest reveals that the lower portion of the sternum is depressed. Auscultation of the lungs and heart is unremarkable. What disorder of the thorax best describes these findings? a) Barrel chest b) Thoracic kyphoscoliosis c) Funnel chest (pectus excavatum) d) Pigeon chest (pectus carinatum)
C)Funnel Chest
Adventitious sounds are heard when auscultating a client's lungs. Which of the following would the nurse do first? a) Auscultate for egophony b) Perform bronchophony c) Have the client cough and then listen again d) Refer the client for further medical evaluation
C)Have the client cough and then listen again
A client reports sharp and stabbing chest pain that worsens with deep breathing and coughing. A cardiac cause to this pain is ruled out. The description of the pain is consistent with what respiratory condition? a) Asthma b) Pneumonia c) Pleurisy d) Rales
C)Pleurisy
The nurse is preparing to auscultate the posterior thorax of an adult female client. The nurse should a) place the bell of the stethoscope firmly on the posterior chest wall. b) auscultate from the base of the lungs to the apices. c) ask the client to breathe deeply through her mouth. d) ask the client to breathe normally through her nose.
C)ask the client to breathe deeply through her mouth
A 25-year-old male patient is brought to the emergency department by ambulance after being involved in a motor vehicle accident. You find that he has decreased breath sounds over the left lung fields. What might you suspect is the cause? a) Pneumothorax b) Atelectasis c) Muscular weakness d) Asthma
a)Pneumothorax
The nurse documents vesicular lung sounds upon auscultation. The nurse heard what type of sound? a) sound heard throughout inspiration and two thirds of expiration b) expiratory sounds lasting longer than inspiratory c) short silence between inspiration and expiration d) inspiratory and expiratory sounds equal in length
a)sound heard throughout inspiration and two thirds of expiration
During the lung assessment for a client with pneumonia, the nurse auscultates low-pitched, bubbling, moist sounds that persist from early inspiration to early expiration. How should the nurse document these sounds? a) Sonorous wheezes b) Sibilant wheezes c) Pleural friction rubs d) Coarse crackles
d)coarse crackles
