ATI Health Assess 2.0: Respiratory

a nurse is auscultating the breath sounds of a client who has pneumonia and hears bronchial crackles. In which of the following areas of the chest is the nurse auscultating?

A (heard to the right and left of the trachea and larynx. They can only be heard on the anterior chest

a nurse is caring for a client who is dying and is having periods of deep breathing alternating with periods of apnea. The nurse should identify this as which of the following types of breathing?

Cheyne-Stokes breathing

a charge nurse is observing a newly licensed nurse perform an anterior chest auscultation on a client. For which of the following actions should the charge nurse intervene?

The nurse is auscultating through the client's gown

a nurse is caring for a client who is having difficulty breathing. Which of the following actions should the nurse take first?

elevate the head of the client's bed

a charge nurse is reviewing the documentation of a newly licensed nurse. Which of the following entries made by the newly licensed nurse is an example of correct documentation?

inspiratory wheeze auscultated at left lateral chest

a nurse is providing discharge instructions to a client who has COPD regarding the influenza vaccine. Which of the following statements should the nurse make?

You should make every effort to receive a flu vaccine every year

a nurse in the emergency department is assessing a client who has experienced thoracic trauma from a motor-vehicle crash. Which of the following findings is an indication of pneumothorax?

the client is experiencing unequal movement of the posterior chest

a nurse is auscultating the lateral lobes of a client who has bronchitis. The nurse should document the sound of as which of the following?

wheeze

A nurse is reviewing the medical record of a client who was assessed as having a barrel chest resulting from COPD. Which of the following images shows a client who has a barrel chest?

The top answer (the anterior/posterior to transverse diameter is equal, and the ribs, normally in a downward slope, lay horizontal. The client might sit in a tripod position to obtain adequate oxygen exchange

a charge nurse is teaching a newly licensed nurse how to recognize manifestations of decreased oxygenation in a client. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

clubbing of the fingers indicates a chronic state of impaired perfusion

A nurse is performing a head to toe assessment of a client. Which of the following findings indicate the client might be experiencing respiratory difficulty?

> the client is sitting in tripod position > the client is using pursed lipped breathing > the client appears confused

a charge nurse is teaching a newly licensed nurse how to recognize a pleural friction rub. Which of the following descriptions should the nurse use to describe a pleural friction rub?

>coarse grating tone >heard on inspiration and expiration >pain with breathing

a nurse is admitting a client who has a new diagnosis of COPD. Which of the following information documented by the nurse is subjective data?

>report from client says they sleep while propped on two pillows at night >client says they quit smoking 2 years ago > client states: being short of breath all of the time is making me depressed

a nurse is preparing to auscultate a client's posterior and lateral chest. In which order should the nurse perform the following actions?

>expose the posterior chest with the client sitting with their arms folded across their chest >auscultate 8cm to one side of the spine around c7, then auscultate the other side of the spine in the same location >auscultate down the spine, moving the stethoscope from one side to the other until the lower thoracic spine is reached >auscultate the lateral sides slightly below the axillary area, then down to the seventh or eighth rib

a nurse is assessing a client who is dark-skinned. In which of the following areas of the client's body should the nurse assess the client for adequate oxygenation?

>nail beds >oral mucosa >lips

a nurse is caring for a client who is experiencing episodes of hyperventilation. Which of the following manifestations should the nurse expect during hyperventilation?

>numbness and tingling of extremities >lightheadedness >chest pain

a nurse is providing teaching to a client who has a new diagnosis of asthma and reports a smoking history of 20 years. Which of the following statements should the nurse make when counseling the client about their tobacco use?

>smoking is linked to various forms of cancer >it might take several attempts to finally stop smoking >there are pharmacological therapies that can help a person stop smoking