FINAL EXAM: Lungs NCLEX

How should a nurse position a client to accurately auscultate the right middle lobe of the lung? a. lean forward at the waist b. move the right arm away from the body c. rest the arms on the knees d. lateral with the right lung facing up

b. move the right arm away from the body

When percussing the anterior chest for tone, a nurse should anticipate what tone over the majority of the lung fields? a. dullness b. resonance c. tympany d. hyperresonance

b. resonance

What characteristic nail color should the nurse recognize as an indication of hypoxia? a. yeloowish b. pink c. greenish d. cyanotic

d. cyanotic

A nurse auscultates a client's lungs and hears fine crackles. What is an appropriate action by the nurse? a. listen again with the bell of the stethoscope b. instruct the client to cough forcefully c. have the client breath through the mouth d. assess for the use of accessory muscles

b. instruct the client to cough forcefully

On examination, the nurse notes a costal angle greater than 90 degrees. What would the nurse suspect? a) Chronic obstructive pulmonary disease b) Pneumothorax c) Infant respiratory distress syndrome d) Atelectasis

a) Chronic obstructive pulmonary disease

A nurse is palpating the sternum of a client. If the client is healthy, which of the following would characterize his costal angle? a. 110 degrees b. less than 90 degrees c. 100 degrees d. 110 degrees

b. less than 90 degrees

What is the correct use of the stethoscope to auscultate breath sounds? a) Listen to at least one full respiration in each location. b) Listen as the client inhales, then go to the next site. c) Have the client breath in and out rapidly as the nurse listens. d) If the client is embarrassed, listen over his hospital gown.

a) Listen to at least one full respiration in each location.

Air passing through narrowed bronchioles would produce what adventitious sound? a) Wheezes b) Bronchial c) Bronchophony d) Whispered pectoriloquy

a) Wheezes

A nurse is interviewing a client who complains of dyspnea of sudden onset. Base on this finding, the nurse should suspect which of the following causes? a. bacterial infection b. sleep apnea c. lung cancer d. emphysema

a. bacterial infection

Upon inspection of a client's chest, a nurse observes an increase in the ratio of anteroposterior to transverse diameter. The nurse recognizes this as a finding in which disease process? a. chronic obstructive pulmonary disease b. pneumothorax c. tuberculosis d. carcinoma of the lungs

a. chronic obstructive pulmonary disease

A client reports to the nurse that he experiences fatigue during the day, has difficulty sleeping lying down, and often wakes up at night feeling short of breath. The nurse should assess this client for other findings related to what disease process? a. heart failure b. paroxysmal nocturnal c. sleep apnea d. upper respiratory infection

a. heart failure

A 60 year old male client presents to the health clinic with a 3 week history of cough, pleuritic chest pain, increasing fatigue, and intermittent fevers. Which data collected in the history should the nurse recognize as risk factors for the development of lung cancer? select all that apply a. history of radiation exposure b. high-fat diet c. moderate alcohol consumption d. smokeless tobacco e. exposure to asbestos at work

a. history of radiation exposure e. exposure to asbestos at work

A nurse assesses the respiration pattern on a client who arrives in the emergency department due to an overdoes of narcotics. The nurse notes that the respirations are decreased in rate and depth, and have an irregular pattern. How should the nurse document this finding? a. hypoventilation b. bradypnea c. biot's respiration d. cheyne-stoke's respiration

a. hypoventilation

which action by a nurse demonstrates the proper sequence for auscultation of the lung fields? a. listen at each site for at least one complete respiratory cycle b. use the diaphragm then the bell in each location c. instruct the client to breathe in and out rapidly through the mouth d. move from anterior to posterior on the same side

a. listen at each site for at least one complete respiratory cycle

A nurse observes a client sitting in the tripod position. What is an appropriate action by the nurse in response to this observation? a. observe for the use of accessory muscles b. auscultate for the presence of crackles c. percuss to determine diaphragmatic excursion d. palpate for tactile fremitus

a. observe for the use of accessory muscles

a client is admitted to the health care facility with a diagnosis of left lower lobe pneumonia. What change in egophony should the nurse expect to find in the left lower lobe? a. sound is louder and sounds like "A" b. "ninty nine" is soft and muffled c. "1-2-3" is heard clearly d. letter "E" is heard distinctly

a. sound is louder and sounds like "A"

Which finding during assessment of a client should alert the nurse to the presence of a persistent atelectasis? a. unequal expansion of the chest b. the presence of crepitus on palpation c. a depressed sternum and cartilages d. retraction of intercostal spaces

a. unequal expansion of the chest

A client with chronic obstructive pulmonary disease (COPD) comes to the clinic complaining that his breathing is getting more difficult over the last couple of weeks. What question would be best to help the nurse understand the hypoxia the client is experiencing? a) "Do you think oxygen will help you?" b) "In what ways have your activities been affected?" c) "Do you have a cough?" d) "Have you been taking your medications?"

b) "In what ways have your activities been affected?"

A client comes to the clinic complaining of a productive cough. What would be the most important question to ask? a) "How long have you been smoking?" b) "What color is the sputum?" c) "What treatments have you tried?" d) "Does the cough wake you up at night?"

b) "What color is the sputum?"

A nurse is auscultating the voice sounds of a client with consolidation in his left lower lobe of his lung due to tumor. Which of the following findings should the nurse expect on performing pectoriloquy? a. sound is louder and sounds like "A" b. "1-2-3" is heard clearly c. letter "E" is heard clearly d. "Ninety-nine" is soft and muffled

b. "1-2-3" is heard clearly

A nurse is interviewing a client who complains of dyspnea. Which of the following findings tend to indicate an underlying cardiovascular problem in the client? select all that apply a. coughing that produces white sputum b. angina c. snoring and gasping while sleeping d. coughing occurring at night e. orthopnea f. edema

b. angina e. orthopnea f. edema

During the assessment of a client with a pneumothorax, what change should the nurse anticipate when auscultating for fremitus? a. increased b. decreased c. absence d. symmetric

b. decreased

A client is concerned about developing lung cancer, as he smoked foe years. He tells the nurse that he quit smoking last year but wonders if there is anything else he can do to reduce his risk for developing this disease. Which of the following should the nurse recommend? a. wearing SPF 30 sunscreen while outdoors b. having his home checked for radon c. eating a low-fat diet d. researching his family's history of lung cancer

b. having his home checked for radon

The nurse would most likely auscultate fine crackles in which client? a) A healthy 5-year-old b) The pregnant client c) A patient with lobar pneumonia d) A client with a pneumothorax

c) A patient with lobar pneumonia

On auscultation of a client's lungs, the nurse clearly and distinctly hears "ninety- nine." The nurse would recognize this as what? a) Whispered pectoriloquy b) Egophony c) Bronchophony d) Atelectatic crackles

c) Bronchophony

The nurse notes hyperresonant percussion tones when percussing the thorax of an infant. What should the nurse should do? a) Notify the physician immediately b) Suspect a pneumothorax c) Consider this a normal finding and document d) Monitor the infant's respiratory rate and rhythm

c) Consider this a normal finding and document

When auscultating the lungs of an adult client, the nurse notes low-pitched, soft breath sounds, with inspiration being longer then expiration over the posterior lower lobes. The nurse's response would be based on what? a) These sounds are normally auscultated over the trachea. b) These are bronchial breath sounds normally heard in this location . c) These are vesicular breath sounds normally heard in this location d) These are bronchovesicular breath sounds normally hear in this location.

c) These are vesicular breath sounds normally heard in this location

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. "how much do you exercise during the week?" b. "Have you changed your diet within the past few weeks?" c. "are you taking any medications on a regular basis?" d. "do you feel that you are under a great deal of stress?"

c. "are you taking any medications on a regular basis?"

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. hypoventilation c. bradypnea d. hyperventilation

c. bradypnea

Which characteristic feature of the sternum should the nurse observe in a client with the diagnosis of pectus carinatum? a. horizontal sternum with increased intercostal angle b. midline and straight c. forward perfusion d. sunken along with adjacent cartilages

c. forward perfusion

A client presents to the health care facility with 2-week history of persistent dry, hacky cough, chest tightness, and shortness of breath with activity. The client admits to a 1-pack-per-day history of cigarette smoking for 20 years. The nurse observes a respiratory rate of 16 breaths per minute, easy and regular. Which nursing diagnosis should the nurse confirm based on this assessment data? a. risk for imbalanced nutrition b. disturbed sleep pattern c. impaired gas exchange d. ineffective airway clearance

c. impaired gas exchange

A nurse is auscultating the bronchi of a client. The nurse understands that the bronchi are located in which of the following locations in the body? a. at the level of the 12th rib on the left scapular line b. at the level of the 8th rib on the right mid-clavicular line c. in the mediastinum d. at the base of the lungs

c. in the mediastinum

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 breath, and inability to cough up secretions. Which nursing diagnosis can be confirmed with this data? a. ineffective breathing pattern b. impaired gas exchange c. ineffective airway clearance d. risk for respiratory infection

c. 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. assess for symmetry of chest expansion b. report this to health care provider immediately c. observe the client's respiratory rate and pattern d. ask the client how long they have to rest between activities

c. 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 the stethoscope on the posterior chest wall, ask the client to take a deep breath, and observe chest rise and fall c. place both hands 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

c. place both hands on the posterior chest wall, ask the client to take a deep breath, and observe chest rise and fall

What statement describes normal changes in an older adult? a) Severe dyspnea on exertion b) Increased respiratory muscle strength c) Decrease in small airway closure d) Lungs less elastic and distensible

d) Lungs less elastic and distensible

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. retractive b. kussmauls c. cheyne-stokes d. biots

d. biots

Which type of breath sounds should a nurse anticipate on auscultation of the right lower lobe in a client with right lower lobe pneumonia? a. vesicular b. diminished c. bronchovesicular d. bronchial

d. bronchial

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. Sibilant wheezes b. pleural friction rubs c. sonorous wheezes d. coarse crackles

d. coarse crackles

A nurse palpates for tactile fremitus and notes that the vibrations diminish towards the base of the lungs. What should the nurse recognize about this finding? a. atelectasis has occurred b. client needs to speak louder c. an area of consolidation is present d. decreasing intensity is normal at the base

d. decreasing intensity is normal at the base

A nurse inspects the anterior thorax of a client with emphysema. Which change in the thorax should the nurse recognize as normal for this client? a. forward protrusion of the sternum causing the ribs to slope backwards b. anterior posterior diameter is less than the transverse diameter c. retraction of the intercostal spaces with an increase in respiratory effort d. horizontal position to the ribs with a costal angle of greater than 90 degrees

d. horizontal position to the ribs with a costal angle of greater than 90 degrees

A nurse is auscultating a client's chest for breath sounds, The nurse recognizes that which of the following is the strongest stimulus to breath? a. hypoxemia b. hyperventilation c. hypoventilation d. hypercapnia

d. hypercapnia

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. non-protruding, symmetrical scapulae c. shoulders and scapulae at a horizontal position d. lateral deviation of the spinous processes

d. lateral deviation of the spinous processes

Which characteristic of a cough should alert the nurse to assess the client for other findings of sinusitis? a. persistent all day b. intermittent but worse in evening c. onset upon awakening d. nighttime when lying down

d. nighttime when lying down

While performing an assessment of a client who sustained a chest injury, which physical examination technique should the nurse use to elicit crepitus? a. percussion b. auscultation c. inspection d. palpation

d. palpation

A nurse is assessing a client with acute asthma. Which adventitious breath sound should the nurse expect to hear in this client? a. sonorous wheezes heard primarily during expiration but may be heard throughout the respiratory cycle b. course crackles occurring from early inspiration to early expiration c. fine crackles occurring late in respiration d. sibilant wheezes heard primarily during expiration but may also be heard on inspiration

d. sibilant wheezes heard primarily during expiration but may also be heard on inspiration

In palpating the chest of a client, a nurse feels a U-shaped indentation on the superior border of the manubrium. The nurse recognizes this landmark as which of the following? a. xiphoid process b. acromion of the scapula c. sternal angle d. suprasternal notch

d. suprasternal notch