Sie sind auf Seite 1von 5

Respiratory system

1. A patient with acute shortness of breath is admitted to the hospital. Which action should the nurse
take during the initial assessment of the patient?
a) Ask the patient to lie down to complete a full physical assessment.
b) Briefly ask specific questions about this episode of respiratory distress
c) Complete the admission database to check for allergies before treatment.
d) Delay the physical assessment to first complete pulmonary function tests

2. On auscultation of a patient’s lungs, the nurse hears low-pitched, bubbling sounds during inhalation
in the lower third of both lungs. How should the nurse document this finding?
a) Inspiratory crackles at the bases
b) Expiratory wheezes in both lungs.
c) Abnormal lung sounds in the apices of both lungs.
d) Pleural Friction rub in the right and left lower lobes

3. The nurse assesses a client after an open lung biopsy. Which assessment finding is matched with the
correct intervention?
a) Client feels “dizzy;” nurse applies oxygen and pulse oximeter.
b) Client’s heart rate is 55 beats/min; nurse withholds pain medication.
c) Client has reduced breath sounds; nurse calls physician immediately.
d) Client’s respiratory rate is 18 breaths/min; nurse decreases oxygen flow rate.

4. The nurse is caring for four clients who had arterial blood gases (ABGs). Which laboratory value
warrants immediate intervention by the nurse?
a. HCO 3 – of 25 mEq/L
b. SpO 2 of 96%
c. pH of 7.38
d. PaCO 2 of 48 mm Hg

5. A nurse obtains the health history of a client who is recently diagnosed with lung cancer and
identifies that the client has a 60–pack-year smoking history. Which action is most important for the
nurse to take when interviewing this client?
a) Tell the client that he needs to quit smoking to stop further cancer development.
b) Encourage the client to be completely honest about both tobacco and marijuana use.
c) Maintain a nonjudgmental attitude to avoid causing the client to feel guilty
d) Avoid giving the client false hope regarding cancer treatment and prognosis
6. A 3-yr-old boy is undergoing mechanical ventilation 12 hr after repair of an atrial septal defect.
Opioids and benzodiazepines are being used for analgesia and sedation. The mandatory ventilatory
rate has been decreased from 20 to 10 breaths/min in preparation for removal of the endotracheal
tube. The arterial PO2 is 120 mm Hg and the arterial PCO2 is 75 mm Hg. The arterial pH is 7.13. The
child has no spontaneous respirations. Auscultation of the chest demonstrates that the breath
sounds are slightly reduced on the left side. Occasional crackles can be heard over both bases. The
most likely reason for this child's acidosis is:
a) Pulmonary edema
b) Pneumonia
c) Cardiogenic shock
d) Respiratory depression

7. A 3-month-old infant is brought to the emergency room because of lethargy and poor
feeding. She appears pale. Other findings include subcostal retractions and use ofthe
abdominal muscles during expiration. Her breathing rate is 30/min. Breath sounds are
decreased bilaterally. She has a prolonged expiratory phase. No wheezing or crackles are
audible.An abnormality in which of the following components of the respiratory system is
most likely to be involved in the genesis of these manifestations ?
a) Alveolar surfactant
b) Lung interstitium
c) Intrathoracic airways
d) Diaphragm

8. The most common bronchial foreign body is:


a) Raw carrot fragments
b) Popcorn
c) Nut fragments, particularly peanuts
d) Nails

9. An adult patient with a history of allergies comes to the clinic complaining of wheezing and difficulty
in breathing when working in his yard. The assessment findings include tachypnea, use of accessory
neck muscles, prolonged expiration, intercostal retractions, decreased breath sounds, and
expiratory wheezes. The nurse interprets that these assessment findings are consistent with:
a) asthma.
b) atelectasis.
c) lobar pneumonia.
d) heart failure.

10. During auscultation of breath sounds, the nurse should use the stethoscope correctly, in which of
the following ways?
a) Listen to at least one full respiration in each location.
b) Listen as the patient inhales and then go to the next site during exhalation.
c) Have the patient breathe in and out rapidly while the nurse listens to the breath sounds.
d) If the patient is modest, listen to sounds over his or her clothing or hospital gown.

11. During palpation of the anterior chest wall, the nurse notices a coarse, crackling sensation over the
skin surface. On the basis of these findings, the nurse suspects:
a) tactile fremitus.
b) crepitus.
c) friction rub.
d) adventitious sounds

12. The nurse is auscultating the lungs of a patient who had been sleeping and notices short, popping,
crackling sounds that stop after a few breaths. The nurse recognizes that these breath sounds are:
a) atelectatic crackles, and that they are not pathologic.
b) fine crackles, and that they may be a sign of pneumonia.
c) vesicular breath sounds.
d) fine wheezes

11. The nurse is listening to the breath sounds of a patient with severe asthma. Air passing through
narrowed bronchioles would produce which of these adventitious sounds?
a) Wheezes
b) Bronchial sounds
c) Bronchophony
d) Whispered pectoriloquy

12. During auscultation of the lungs of an adult patient, the nurse notices the presence of
bronchophony. The nurse should assess for signs of which condition?
a) Airway obstruction
b) Emphysema
c) Pulmonary consolidation
d) Asthma

13. The nurse knows that auscultation of fine crackles would most likely be noticed in:
a) a healthy 5-year-old child.
b) a pregnant woman.
c) the immediate newborn period.
d) association with a pneumothorax

14. The nurse is percussing over the lungs of a patient with pneumonia. The nurse knows that
percussion over an area of atelectasis in the lungs would reveal:
a) dullness.
b) tympany.
c) resonance.
d) Hyperresonance

15. The nurse is reviewing the technique of palpating for tactile fremitus with a new graduate. Which
statement by the graduate nurse reflects a correct understanding of tactile fremitus? "Tactile
fremitus:
a) is caused by moisture in the alveoli."
b) indicates that there is air in the subcutaneous tissues."
c) is caused by sounds generated from the larynx."
d) reflects the blood flow through the pulmonary arteries."

16. When auscultating the lungs of an adult patient, the nurse notes that over the posterior lower lobes
low-pitched, soft breath sounds are heard, with inspiration being longer than expiration. The nurse
interprets that these are:
a) sounds normally auscultated over the trachea.
b) bronchial breath sounds and are normal in that location.
c) vesicular breath sounds and are normal in that location.
d) bronchovesicular breath sounds and are normal in that location.

17. A 65-year-old patient with a history of heart failure comes to the clinic with complaints of "being
awakened from sleep with shortness of breath." Which action by the nurse is most appropriate?
a) Obtain a detailed history of the patient's allergies and history of asthma.
b) Tell the patient to sleep on his or her right side to facilitate ease of respirations.
c) Assess for other signs and symptoms of paroxysmal nocturnal dyspnea.
d) Assure the patient that this is normal and will probably resolve within the next week.

18. When assessing tactile fremitus, the nurse recalls that it is normal to feel tactile fremitus most
intensely over which location?
a) Between the scapulae
b) Third intercostal space, MCL
c) Fifth intercostal space, MAL
d) Over the lower lobes, posterior side

19. When assessing a patient's lungs, the nurse recalls that the left lung:
a) consists of two lobes.
b) is divided by the horizontal fissure.
c) consists primarily of an upper lobe on the posterior chest.
d) is shorter than the right lung because of the underlying stomach.

20. During an assessment, the nurse knows that expected assessment findings in the normal adult lung
include the presence of:
a) adventitious sounds and limited chest expansion.
b) increased tactile fremitus and dull percussion tones.
c) muffled voice sounds and symmetrical tactile fremitus.
d) absent voice sounds and hyperresonant percussion tones.