Question 1

The nurse is preparing to assess a client with atelectasis. Which objective finding should the nurse anticipate?

Accepted Answer

A)   Clubbing of the fingers.
B)   Decreased or absent breath over the affected area.
C)   No voice transmission.
D)   Decreased chest wall expansion on the affected side.

Question 2

The nurse is preparing to identify the angle of Louis prior to a thoracic assessment. Which landmark should the nurse use to identify this structure?

Accepted Answer

A)   Clavicle.
B)   Sternum.
C)   First rib.
D)   Vertebral column.

Question 3

The educator has reviewed the respiratory system for a nurse. Which statement made by the nurse indicates further teaching is required?

Accepted Answer

A)   "The left main bronchus is shorter."
B)   "The bronchi begin at the level of the sternal angle."
C)   "The bronchi divide within each lobe of the lung."
D)   "The bronchi warm and moisten air."

Question 4

The nurse is reviewing the records of a client with severe left pleural effusion. Which assessment finding should the nurse anticipate? Select all that apply.

Accepted Answer

A)   Absent breath sounds on the left side.
B)   Tracheal shift to the right.
C)   Hyperresonance upon percussion.
D)   Bronchial breath sounds on the right side.
E)   Pleural friction rub. A,B,E

Question 5

The educator is observing the nurse's technique for a lung assessment. Which should the educator recognize demonstrates appropriate technique?

Accepted Answer

A)   Auscultation begins from the base to apices of lungs.
B)   Auscultation up one side of the thorax and then up the other.
C)   Auscultation down one side of the thorax and then down the other.
D)   Auscultation bilaterally from one side to the other.

Question 6

The nurse notes movement on one side of the chest while palpating respiratory expansion. Which conditions should the nurse suspect is associated with this assessment finding? Select all that apply.

Accepted Answer

A)   Atelectasis.
B)   Chronic bronchitis.
C)   Lobar pneumonia.
D)   Pleural effusion.
E)   Congestive heart failure. A,C,D

Question 7

The nurse is preparing to assess a client with scoliosis. Which assessment findings should the nurse anticipate?

Accepted Answer

A)   An exaggerated posterior curvature of the thoracic spine.
B)   A lateral curvature and rotation of the thoracic and lumbar spine.
C)   Forward displacement of the sternum with depression of the adjacent costal cartilage.
D)   Depression of the sternum and the adjacent costal cartilage.

Question 8

The nurse is assessing the client's respiratory pattern and notes periods of deep breathing alternating with periods of apnea. Which terminology should the nurse use to document the findings?

Accepted Answer

A)   Tachypnea.
B)   Obstructive breathing.
C)   Hypoventilation.
D)   Cheyne-Stokes.

Question 9

The nurse is preparing to assess the client's respiratory system. Which order should the nurse conduct the assessment? 
A) Auscultation.
B) Inspection.
C) Percussion.
D) Client survey.
E) Palpation.

Accepted Answer

D,B,E,C,and A

Question 10

The nurse auscultating a client's lungs notes there is a low-pitched, continuous respiratory sounds that has a snoring quality. Which terminology should the nurse use to document the finding?

Accepted Answer

A)   Rales.
B)   Crackles.
C)   Rhonchi.
D)   Wheezes.

Question 11

The nurse reviewing a client's record notes that the client has a fractured floating rib. Which rib should the nurse identify has been fractured?

Accepted Answer

A)   1st.
B)   5th.
C)   9th.
D)   12th.

Question 12

The nurse is reviewing the records of a client with chronic bronchitis. Which assessment finding should the nurse anticipate?

Accepted Answer

A)   Fever.
B)   Decreased respiratory rate.
C)   Use of accessory muscles.
D)   Dry cough.

Question 13

Which is the primary landmark used to identify and locate all of the other landmarks on the anterior chest?

Accepted Answer

A)   Sternum.
B)   Manubrium.
C)   Suprasternal notch.
D)   Angle of Louis.

Question 14

A client asks the nurse why they are being evaluated for weight loss during a respiratory assessment. Which response should the nurse provide the client as the primary reason weight loss is assessed?

Accepted Answer

A)   "Weight loss reflects poor nutrition which may affect the strength of respiratory muscles."
B)   "Weight loss may have occurred as a result of lung or other diseases.
C)   "Weight loss may be associated with poor nutrition which may interfere with the exchange of oxygen and carbon dioxide."
D)   "Weight loss may be associated with nutritional deficiencies and places you at risk for respiratory infections."

Question 15

The nurse is preparing to auscultate the bronchovesicular sounds of a client. Which landmark should the nurse use to identify the correct placement of the stethoscope?

Accepted Answer

A)   Anterior of the angle of Louis and lateral of the sternum in the second intercostal space.
B)   Second and third intercostal spaces between scapulae.
C)   Next to the trachea superior in each clavicle and in the first intercostal space.
D)   Superiorly to the manubrium and anterior midclavicular.

Question 16

The nurse identifies abnormal breath sounds during an assessment. Which sounds should the nurse document as abnormal? Select all that apply.

Accepted Answer

A)   Crackles.
B)   Vesicular.
C)   Bronchovesicular.
D)   Wheezes.
E)   Bronchial.

Question 17

The nurse notes a client has a barrel chest. Which question should the nurse ask the client?

Accepted Answer

A)   "Do you have a history of pneumonia?"
B)   "Do you have a history of emphysema?"
C)   "Have you ever been exposed to tuberculosis?"
D)   "Have you ever been diagnosed with scoliosis?"

Question 18

The nurse notes the client's respiration rate is 14 per minute and the expiration phase is the same length as the end-inspiration phase. Which term should the nurse use to document the findings?

Accepted Answer

A)   Obstructive breathing.
B)   Bradypnea.
C)   Respiratory distress.
D)   Eupnea.

Question 19

The nurse is preparing to auscultate the breath sounds of a client with asthma. Which breath sounds does the nurse anticipate to find upon assessment?

Accepted Answer

A)   High pitch continuous sounds on inspiration and expiration.
B)   Low pitch continuous rattling on inspiration and expiration.
C)   High pitched short crackling.
D)   Low pitched grating and rubbing on inhalation and exhalation.

Question 20

The nurse is assessing the client's respiratory system. Which method will result in the most accurate assessment of the client's respiratory rate?

Accepted Answer

A)   The nurse should place a hand on the client's chest to count respirations.
B)   The nurse should inform the client that they are preparing to count the client's respirations.
C)   The nurse should count when the respirations are audible.
D)   The nurse should count the respirations in an unobtrusive manner without informing the client.

Exam 16: Lungs and Thorax

The nurse is preparing to assess a client with atelectasis. Which objective finding should the nurse anticipate?

Correct AnswerverifiedShow Answer

The nurse is preparing to identify the angle of Louis prior to a thoracic assessment. Which landmark should the nurse use to identify this structure?

Correct AnswerverifiedShow Answer

The educator has reviewed the respiratory system for a nurse. Which statement made by the nurse indicates further teaching is required?

Correct AnswerverifiedShow Answer

The nurse is reviewing the records of a client with severe left pleural effusion. Which assessment finding should the nurse anticipate? Select all that apply.

Correct AnswerverifiedA,B,E

The educator is observing the nurse's technique for a lung assessment. Which should the educator recognize demonstrates appropriate technique?

Correct AnswerverifiedShow Answer

The nurse notes movement on one side of the chest while palpating respiratory expansion. Which conditions should the nurse suspect is associated with this assessment finding? Select all that apply.

Correct AnswerverifiedA,C,D

The nurse is preparing to assess a client with scoliosis. Which assessment findings should the nurse anticipate?

Correct AnswerverifiedShow Answer

The nurse is assessing the client's respiratory pattern and notes periods of deep breathing alternating with periods of apnea. Which terminology should the nurse use to document the findings?

Correct AnswerverifiedShow Answer

The nurse is preparing to assess the client's respiratory system. Which order should the nurse conduct the assessment? A) Auscultation. B) Inspection. C) Percussion. D) Client survey. E) Palpation.

Correct AnswerverifiedD,B,E,C,and A

The nurse auscultating a client's lungs notes there is a low-pitched, continuous respiratory sounds that has a snoring quality. Which terminology should the nurse use to document the finding?

Correct AnswerverifiedShow Answer

The nurse reviewing a client's record notes that the client has a fractured floating rib. Which rib should the nurse identify has been fractured?

Correct AnswerverifiedShow Answer

The nurse is reviewing the records of a client with chronic bronchitis. Which assessment finding should the nurse anticipate?

Correct AnswerverifiedShow Answer

Which is the primary landmark used to identify and locate all of the other landmarks on the anterior chest?

Correct AnswerverifiedShow Answer

A client asks the nurse why they are being evaluated for weight loss during a respiratory assessment. Which response should the nurse provide the client as the primary reason weight loss is assessed?

Correct AnswerverifiedShow Answer

The nurse is preparing to auscultate the bronchovesicular sounds of a client. Which landmark should the nurse use to identify the correct placement of the stethoscope?

Correct AnswerverifiedShow Answer

The nurse identifies abnormal breath sounds during an assessment. Which sounds should the nurse document as abnormal? Select all that apply.

Correct AnswerverifiedShow Answer

The nurse notes a client has a barrel chest. Which question should the nurse ask the client?

Correct AnswerverifiedShow Answer

The nurse notes the client's respiration rate is 14 per minute and the expiration phase is the same length as the end-inspiration phase. Which term should the nurse use to document the findings?

Correct AnswerverifiedShow Answer

The nurse is preparing to auscultate the breath sounds of a client with asthma. Which breath sounds does the nurse anticipate to find upon assessment?

Correct AnswerverifiedShow Answer

The nurse is assessing the client's respiratory system. Which method will result in the most accurate assessment of the client's respiratory rate?

Correct AnswerverifiedShow Answer

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A,B,E

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A,C,D

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D,B,E,C,and A

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