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Unformatted text preview: Assessment of Respiratory System (25)
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. The nurse prepares a patient with a left-sided pleural effusion for a thoracentesis. How should the nurse position the
a. High-Fowler’s position with the left arm extended
b. Supine with the head of the bed elevated 30 degrees
c. On the right side with the left arm extended above the head
d. Sitting upright with the arms supported on an over bed table
3. A diabetic patient’s arterial blood gas (ABG) results are pH 7.28; PaCO 2 34 mm Hg; PaO2 85 mm Hg; HCO3– 18
mEq/L. The nurse would expect which finding?
a. Intercostal retractions
c. Low oxygen saturation (SpO2)
b. Kussmaul respirations
d. Decreased venous O2 pressure
4. 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
5. The nurse palpates the posterior chest while the patient says “99” and notes absent fremitus. Which action should the
nurse take next?
a. Palpate the anterior chest and observe for barrel chest.
b. Encourage the patient to turn, cough, and deep breathe.
c. Review the chest x-ray report for evidence of pneumonia.
d. Auscultate anterior and posterior breath sounds bilaterally.
6. A patient with a chronic cough is scheduled to have a bronchoscopy with biopsy. Which intervention will the nurse
implement directly after the procedure?
a. Encourage the patient to drink clear liquids.
b. Place the patient on bed rest for at least 4 hours.
c. Keep the patient NPO until the gag reflex returns.
d. Maintain the head of the bed elevated 90 degrees.
7. The nurse completes a shift assessment on a patient admitted in the early phase of heart failure. When auscultating
the patient’s lungs, which finding would the nurse most likely hear?
a. Continuous rumbling, snoring, or rattling sounds mainly on expiration
b. Continuous high-pitched musical sounds on inspiration and expiration
c. Discontinuous, high-pitched sounds of short duration during inspiration
d. A series of long-duration, discontinuous, low-pitched sounds during inspiration
8. The nurse observes that a patient with respiratory disease experiences a decrease in SpO 2 from 93% to 88% while the
patient is ambulating. What is the priority action of the nurse?
a. Notify the health care provider.
b. Administer PRN supplemental O2.
c. Document the response to exercise.
d. Encourage the patient to pace activity.
9. The nurse teaches a patient about pulmonary spirometry testing. Which statement, if made by the patient, indicates
teaching was effective?
a. “I should use my inhaler right before the test.”
b. “I won’t eat or drink anything 8 hours before the test.”
c. “I will inhale deeply and blow out hard during the test.”
d. “My blood pressure and pulse will be checked every 15 minutes.”
10. The nurse observes a student who is listening to a patient’s lungs. Which action by the student indicates a need to
review respiratory assessment skills?
a. The student compares breath sounds from side to side at each level.
b. The student listens during the inspiratory phase, then moves the stethoscope.
c. The student starts at the apices of the lungs, moving down toward the lung bases.
d. The student instructs the patient to breathe slowly and deeply through the mouth. 11. A patient who has a history of chronic obstructive pulmonary disease (COPD) was hospitalized for increasing
shortness of breath and chronic hypoxemia (SaO2 levels of 89% to 90%). In planning for discharge, which action by the
nurse will be most effective in improving compliance with discharge teaching?
a. Have the patient repeat the instructions immediately after teaching.
b. Accomplish the patient teaching just before the scheduled discharge.
c. Arrange for the patient’s caregiver to be present during the teaching.
d. Start giving the patient discharge teaching during the admission process.
12. A patient admitted to the emergency department complaining of sudden onset shortness of breath is diagnosed with a
possible pulmonary embolus. How should the nurse prepare the patient for diagnostic testing to confirm the diagnosis?
a. Ensure that the patient has been NPO.
b. Start an IV so contrast media may be given.
c. Inform radiology that radioactive glucose preparation is needed.
d. Instruct the patient to expect to inspire deeply and exhale forcefully.
13. The nurse admits a patient who has a diagnosis of an acute asthma attack. Which statement indicates that the patient
may need teaching regarding medication use?
a. “I have not had any acute asthma attacks during the past year.”
b. “I became short of breath an hour before coming to the hospital.”
c. “I’ve been taking Tylenol 650 mg every 6 hours for chest wall pain.”
d. “I’ve been using my albuterol inhaler more frequently over the last 4 days.”
14. A patient with acute dyspnea is scheduled for a spiral computed tomography (CT) scan. Which information obtained by
the nurse is a priority to communicate to the health care provider before the CT?
a. Allergy to shellfish
c. Respiratory rate of 30
b. Apical pulse of 104
d. O2 saturation of 90%
15. The nurse analyzes the results of a patient’s arterial blood gases (ABGs). Which finding would require immediate
a. The bicarbonate level (HCO3–) is 31 mEq/L.
b. The arterial oxygen saturation (SaO2) is 92%.
c. The partial pressure of CO2 in arterial blood (PaCO2) is 31 mm Hg.
d. The partial pressure of oxygen in arterial blood (PaO 2) is 59 mm Hg.
16. Which assessment finding indicates that the nurse should take immediate action for an older patient?
a. Weak cough effort
c. Dry mucous membranes
b. Barrel-shaped chest
d. Bilateral basilar crackles
17. A patient in metabolic alkalosis is admitted to the emergency department and pulse oximetry (SpO 2) indicates that the
O2 saturation is 94%. Which action should the nurse expect to take next?
a. Complete a head-to-toe assessment.
b. Administer an inhaled bronchodilator.
c. Place the patient on high-flow oxygen.
d. Obtain repeat arterial blood gases (ABGs).
18. After the nurse has received change-of-shift report, which patient should the nurse assess first?
a. A patient with pneumonia who has crackles in the right lung base
b. A patient with chronic bronchitis who has a low forced vital capacity
c. A patient with possible lung cancer who has just returned after bronchoscopy
d. A patient with hemoptysis and a 16-mm induration after tuberculin skin testing
19. The laboratory has just called with the arterial blood gas (ABG) results on four patients. Which result is most important
for the nurse to report immediately to the health care provider?
a. pH 7.34, PaO2 82 mm Hg, PaCO2 40 mm Hg, and O2 sat 97%
b. pH 7.35, PaO2 85 mm Hg, PaCO2 50 mm Hg, and O2 sat 95%
c. pH 7.46, PaO2 90 mm Hg, PaCO2 32 mm Hg, and O2 sat 98%
d. pH 7.31, PaO2 91 mm Hg, PaCO2 50 mm Hg, and O2 sat 96%
20. The nurse assesses a patient with chronic obstructive pulmonary disease (COPD) who has been admitted with
increasing dyspnea over the past 3 days. Which finding is important for the nurse to report to the health care provider?
a. Respirations are 36 breaths/min.
b. Anterior-posterior chest ratio is 1:1.
c. Lung expansion is decreased bilaterally.
d. Hyperresonance to percussion is present.
21. Using the illustrated technique, the nurse is assessing for which finding in a patient with chronic obstructive pulmonary
disease (COPD)? 22. 1. 1. 2. 3. 4. 5. 6. 7. a. Hyperresonance
c. Reduced excursion
b. Tripod positioning
d. Accessory muscle use
Which action is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)?
a. Listen to a patient’s lung sounds for wheezes or crackles.
b. Label specimens obtained during percutaneous lung biopsy.
c. Instruct a patient about how to use home spirometry testing.
d. Measure induration at the site of a patient’s intradermal skin test.
A patient is scheduled for a computed tomography (CT) scan of the chest with contrast media. Which assessment
findings should the nurse report to the health care provider before the patient goes for the CT (select all that apply)?
a. Allergy to shellfish
b. Patient reports claustrophobia
c. Elevated serum creatinine level
d. Recent bronchodilator inhaler use
e. Inability to remove a wedding band
Upper Respiratory Problems (26)
The nurse teaches a patient about discharge instructions after a rhinoplasty. Which statement, if made by the patient,
indicates that the teaching was successful?
a. “My nose will look normal after 24 to 48 hours.”
b. “I can take 800 mg ibuprofen every 6 hours for pain.”
c. “I will remove and reapply the nasal packing every day.”
d. “I will elevate my head for 48 hours to minimize swelling.”
The nurse plans to teach a patient how to manage allergic rhinitis. Which information should the nurse include in the
a. Using oral antihistamines for 2 weeks before the allergy season may prevent reactions.
b. Identifying and avoiding environmental triggers are the best way to prevent symptoms.
c. Frequent hand washing is the primary way to prevent spreading the condition to others.
d. Corticosteroid nasal sprays will reduce inflammation, but systemic effects limit their use.
The nurse discusses management of upper respiratory infections (URIs) with a patient who has acute sinusitis. Which
statement by the patient indicates that additional teaching is needed?
a. “I will drink lots of juices and other fluids to stay well hydrated.”
b. “I can use nasal decongestant spray until the congestion is gone.”
c. “I can take acetaminophen (Tylenol) to treat my sinus discomfort.”
d. “I will watch for changes in nasal secretions or the sputum that I cough up.”
The nurse has just auscultated coarse crackles bilaterally on a patient with a tracheostomy tube in place. If the patient
is unsuccessful in coughing up secretions, what action should the nurse take?
a. Encourage increased incentive spirometer use.
b. Encourage the patient to increase oral fluid intake.
c. Put on sterile gloves and use a sterile catheter to suction.
d. Preoxygenate the patient for 3 minutes before suctioning.
A patient with a tracheostomy has a new order for a fenestrated tracheostomy tube. Which action should the nurse
include in the plan of care in collaboration with the speech therapist?
a. Leave the tracheostomy inner cannula inserted at all times.
b. Place the decannulation cap in the tube before cuff deflation.
c. Assess the ability to swallow before using the fenestrated tube.
d. Inflate the tracheostomy cuff during use of the fenestrated tube.
The nurse is caring for a mechanically ventilated patient with a cuffed tracheostomy tube. Which action by the nurse
would determine if the cuff has been properly inflated?
a. Use a hand-held manometer to measure cuff pressure.
b. Review the health record for the prescribed cuff pressure.
c. Suction the patient through a fenestrated inner cannula to clear secretions.
d. Insert the decannulation plug before removing the nonfenestrated inner cannula.
Which statement by the patient indicates that teaching has been effective for a patient scheduled for radiation therapy
of the larynx?
a. “I will need to buy a water bottle to carry with me.” 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. b. “I should not use any lotions on my neck and throat.”
c. “Until the radiation is complete, I may have diarrhea.”
d. “Alcohol-based mouthwashes will help clean my mouth.”
A nurse obtains a health history from a patient who has a 35 pack-year smoking history. The patient complains of
hoarseness and tightness in the throat and difficulty swallowing. Which question is important for the nurse to ask?
a. “How much alcohol do you drink in an average week?”
b. “Do you have a family history of head or neck cancer?”
c. “Have you had frequent streptococcal throat infections?”
d. “Do you use antihistamines for upper airway congestion?”
A patient scheduled for a total laryngectomy and radical neck dissection for cancer of the larynx asks the nurse, “Will I
be able to talk normally after surgery?” What is the most accurate response by the nurse?
a. “You will breathe through a permanent opening in your neck, but you will not be able to
b. “You won’t be able to talk right after surgery, but you will be able to speak again after the
tracheostomy tube is removed.”
c. “You will have a permanent opening into your neck, and you will need rehabilitation for
some type of voice restoration.”
d. “You won’t be able to speak as you used to, but there are artificial voice devices that will
give you the ability to speak normally.”
A patient who had a total laryngectomy has a nursing diagnosis of hopelessness related to loss of control of personal
care. Which information obtained by the nurse indicates that this identified problem is resolving?
a. The patient allows the nurse to suction the tracheostomy.
b. The patient’s spouse provides the daily tracheostomy care.
c. The patient asks how to clean the tracheostomy stoma and tube.
d. The patient uses a communication board to request “No Visitors.”
The nurse completes discharge instructions for a patient with a total laryngectomy. Which statement by the patient
indicates that additional instruction is needed?
a. “I must keep the stoma covered with an occlusive dressing.”
b. “I need to have smoke and carbon monoxide detectors installed.”
c. “I can participate in my prior fitness activities except swimming.”
d. “I should wear a Medic-Alert bracelet to identify me as a neck breather.”
Which action should the nurse take first when a patient develops epistaxis?
a. Pack the affected nare tightly with an epistaxis balloon.
b. Apply squeezing pressure to the nostrils for 10 minutes.
c. Obtain silver nitrate that may be needed for cauterization.
d. Instill a vasoconstrictor medication into the affected nare.
A nurse is caring for a patient who has had a total laryngectomy and radical neck dissection. During the first 24 hours
after surgery what is the priority nursing action?
a. Monitor the incision for bleeding.
b. Maintain adequate IV fluid intake.
c. Keep the patient in semi-Fowler’s position.
d. Teach the patient to suction the tracheostomy.
After a laryngectomy, a patient coughs violently during suctioning and dislodges the tracheostomy tube. Which action
should the nurse take first?
a. Arrange for arterial blood gases to be drawn immediately.
b. Cover stoma with sterile gauze and ventilate through stoma.
c. Attempt to reinsert the tracheostomy tube with the obturator in place.
d. Assess the patient’s oxygen saturation and notify the health care provider.
Which patient in the ear, nose, and throat (ENT) clinic should the nurse assess first?
a. A patient who is complaining of a sore throat and has a muffled voice
b. A patient who has a “scratchy throat” and a positive rapid strep antigen test
c. A patient who is receiving radiation for throat cancer and has severe fatigue
d. A patient with a history of a total laryngectomy whose stoma is red and inflamed
The nurse obtains the following assessment data on an older patient who has influenza. Which information will be
most important for the nurse to communicate to the health care provider?
a. Fever of 100.4° F (38° C)
b. Diffuse crackles in the lungs
c. Sore throat and frequent cough
d. Myalgia and persistent headache
Which nursing action could the registered nurse (RN) working in a skilled care hospital unit delegate to an experienced
licensed practical/vocational nurse (LPN/LVN) caring for a patient with a permanent tracheostomy? 18. 19. 20. 21. 22. 1. 2. 1. 2.
3. a. Assess the patient’s risk for aspiration.
b. Suction the tracheostomy when directed.
c. Teach the patient to provide tracheostomy self-care.
d. Determine the need for tracheostomy tube replacement.
The nurse is caring for a hospitalized older patient who has nasal packing in place after a nosebleed. Which
assessment finding will require the most immediate action by the nurse?
a. The oxygen saturation is 89%.
b. The nose appears red and swollen.
c. The patient reports level 8 (0 to 10 scale) pain.
d. The patient’s temperature is 100.1° F (37.8° C).
After being hit by a baseball, a patient arrives in the emergency department with a possible nasal fracture. Which
finding by the nurse is most important to report to the health care provider?
a. Clear nasal drainage
b. Complaint of nasal pain
c. Bilateral nose swelling and bruising
d. Inability to breathe through the nose
A patient arrives in the ear, nose, and throat clinic complaining of a piece of tissue being “stuck up my nose” and with
foul-smelling nasal drainage from the right nare. Which action should the nurse take first?
a. Notify the clinic health care provider.
b. Obtain aerobic culture specimens of the drainage.
c. Ask the patient about how the cotton got into the nose.
d. Have the patient occlude the left nare and blow the nose.
The nurse is caring for a patient who has acute pharyngitis caused by Candida albicans. Which action is appropriate
for the nurse to include in the plan of care?
a. Assess patient for allergies to penicillin antibiotics.
b. Teach the patient to sleep in a warm, dry environment.
c. Avoid giving the patient warm food or warm liquids to drink.
d. Teach patient to “swish and swallow” prescribed oral nystatin
When assessing a patient with a sore throat, the nurse notes anterior cervical lymph node swelling, a temperature of
101.6° F (38.7° C), and yellow patches on the tonsils. Which action will the nurse anticipate taking?
a. Teach the patient about the use of expectorants.
b. Use a swab to obtain a sample for a rapid strep antigen test.
c. Discuss the need to rinse the mouth out after using any inhalers.
d. Teach the patient to avoid nonsteroidal antiinflammatory drugs (NSAIDs).
The clinic nurse is teaching a patient with acute sinusitis. Which interventions should the nurse plan to include in the
teaching session (select all that apply)?
a. Decongestants can be used to relieve swelling.
b. Blowing the nose should be avoided to decrease the nosebleed risk.
c. Taking a hot shower will increase sinus drainage and decrease pain.
d. Saline nasal spray can be made at home and used to wash out secretions.
e. You will be more comfortable if you keep your head in an upright position.
The nurse is reviewing the medical records for five patients who are scheduled for their yearly physical examinations in
September. Which patients should receive the inactivated influenza vaccination (select all that apply)?
a. A 76-yr-old nursing home resident
b. A 36-yr-old female patient who is pregnant
c. A 42-yr-old patient who has a 15 pack-year smoking history
d. A 30-yr-old patient who takes corticosteroids for rheumatoid arthritis
e. A 24-yr-old patient who has allergies to penicillin and cephalosporins
Lower Respiratory Problems (27)
After assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of ineffective airway clearance.
Which assessment data best supports this diagnosis?
a. Weak cough effort
b. Profuse green sputum
c. Respiratory rate of 28 breaths/minute
d. Resting pulse oximetry (SpO2) of 85%
The nurse assesses the chest of a patient with pneumococcal pneumonia. Which finding would the nurse expect?
a. Increased tactile fremitus
c. Hyperresonance to percussion
b. Dry, nonproductive cough
d. A grating sound on aus...
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- Fall '19
- Chronic obstructive pulmonary disease, nurse take