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Respiratory Assessment: Questions and Answers for Nursing Students, Exams of Nursing

A series of questions and answers related to respiratory assessment, covering key concepts and techniques used in nursing practice. It is designed to help nursing students prepare for exams and clinical practice by providing a comprehensive review of essential knowledge. Questions on topics such as palpation, percussion, auscultation, and interpretation of breath sounds, as well as common respiratory conditions and their assessment findings.

Typology: Exams

2023/2024

Available from 10/30/2024

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Week 2- Advanced Respiratory Test
Bank Jarvis Chapter 19. Q&A A+ Review
The nurse is teaching the nursing students to palpate the vertebra prominens when
beginning posterior thoracic assessment of a patient. The students will: - ANS-Look for
the spinous process of C7.
When performing a respiratory assessment on a patient, the nurse notes a costal angle
of approximately 90 degrees. This characteristic is: - ANS-A normal finding in a healthy
adult
When assessing a patient's lungs, the nurse recognizes that the left lung: - ANS-
Consists of two lobes.
The nurse landmarks the apices of the lungs to: - ANS-Extend 3 to 4 cm above the
inner third of the clavicles
During an examination of the anterior thorax, the nurse is aware that the trachea
bifurcates anteriorly at the: - ANS-Sternal angle.
During an assessment, the nurse knows that expected assessment findings in the
normal adult lung include the presence of: - ANS-Muffled voice sounds and symmetric
tactile fremitus
The primary respiratory muscles engaged in normal inspiration include the: - ANS-
Diaphragm and intercostals
During assessment of the patient's posterior chest for lung sounds, the nurse will
auscultate the right lung for the: - ANS-Lower lobe, because the upper lobe is too small.
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? - ANS-Assess for other signs and symptoms of paroxysmal nocturnal
dyspnea
When assessing tactile fremitus, the nurse normally feel tactile fremitus most intensely:
- ANS-Between the scapulae
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": - ANS-"Is caused by sounds generated from the
larynx."
During percussion, the nurse knows that a dull percussion note elicited over a lung lobe
most likely results from: - ANS-Increased density of lung tissue.
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Week 2- Advanced Respiratory Test

Bank Jarvis Chapter 19. Q&A A+ Review

The nurse is teaching the nursing students to palpate the vertebra prominens when beginning posterior thoracic assessment of a patient. The students will: - ANS-Look for the spinous process of C7. When performing a respiratory assessment on a patient, the nurse notes a costal angle of approximately 90 degrees. This characteristic is: - ANS-A normal finding in a healthy adult When assessing a patient's lungs, the nurse recognizes that the left lung: - ANS- Consists of two lobes. The nurse landmarks the apices of the lungs to: - ANS-Extend 3 to 4 cm above the inner third of the clavicles During an examination of the anterior thorax, the nurse is aware that the trachea bifurcates anteriorly at the: - ANS-Sternal angle. During an assessment, the nurse knows that expected assessment findings in the normal adult lung include the presence of: - ANS-Muffled voice sounds and symmetric tactile fremitus The primary respiratory muscles engaged in normal inspiration include the: - ANS- Diaphragm and intercostals During assessment of the patient's posterior chest for lung sounds, the nurse will auscultate the right lung for the: - ANS-Lower lobe, because the upper lobe is too small. 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? - ANS-Assess for other signs and symptoms of paroxysmal nocturnal dyspnea When assessing tactile fremitus, the nurse normally feel tactile fremitus most intensely:

  • ANS-Between the scapulae 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": - ANS-"Is caused by sounds generated from the larynx." During percussion, the nurse knows that a dull percussion note elicited over a lung lobe most likely results from: - ANS-Increased density of lung tissue.

The nurse is observing the auscultation technique of another nurse. The correct method to use when progressing from one auscultatory site on the thorax to another is _________________ comparison. - ANS-Side-to-side When auscultating the lungs of an adult patient, the nurse notes that low-pitched, soft breath sounds are heard over the posterior lower lobes, with inspiration being longer than expiration. The nurse interprets these sounds as: - ANS-Vesicular breath sounds and normal in that location The nurse is auscultating the chest of an adult patient. Which technique is correct? - ANS-Firmly holding the diaphragm of the stethoscope against the chest 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 will reveal: - ANS-Dullness During auscultation of the lungs, the nurse expects decreased breath sounds to be heard in which situation? - ANS-When the bronchial tree is obstructed The nurse knows that a normal finding when assessing the respiratory system of an older adult is: - ANS-Decreased mobility of the thorax. A mother brings her 3-month-old infant to the clinic for evaluation of a cold. She tells the nurse that he has had "a runny nose for a week." When performing the physical assessment, the nurse notes that the child has nasal flaring and sternal and intercostal retractions. The nurse's next action should be to: - ANS-Recognize that these are serious signs, and contact the physician. When assessing the respiratory system of a 4-year-old child, which of these findings would the nurse expect? - ANS-Presence of bronchovesicular breath sounds in the peripheral lung fields When inspecting the anterior chest of an adult, the nurse should include which assessment? - ANS-Shape and configuration of the chest wall The nurse knows that auscultation of fine crackles would most likely be noticed in: - ANS-The immediate newborn period During an assessment of an adult, the nurse has noted unequal chest expansion and recognizes that this occurs in which situation? - ANS-When part of the lung is obstructed or collapsed 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? - ANS-Pulmonary consolidation

A patient comes to the clinic complaining of a cough that is worse at night but not as bad during the day. The nurse recognizes that this cough may indicate: - ANS- Postnasal drip or sinusitis. During a morning assessment, the nurse notices that the patient's sputum is frothy and pink. Which condition could this finding indicate? - ANS-Pulmonary edema To correctly auscultate the patient's breath sounds, the nurse will: - ANS-Listen to at least one full respiration in each location Patient has been admitted to the emergency department with a possible medical diagnosis of pulmonary embolism. The nurse expects to see which assessment findings related to this condition? - ANS-Chest pain that is worse on deep inspiration and dyspnea 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: - ANS-Crepitus. 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: - ANS-Atelectatic crackles that do not have a pathologic cause A patient has been admitted to the emergency department for a suspected drug overdose. His respirations are shallow, with an irregular pattern, with a rate of 12 respirations per minute. The nurse interprets this respiration pattern as which of the following? - ANS-Hypoventilation A patient with pleuritis has been admitted to the hospital and complains of pain with breathing. Upon auscultation, the nurse notes coarse, low-pitched sounds with a grating quality and documents them as: - ANS-Friction rub The nurse is assessing voice sounds during a respiratory assessment. Which of these findings indicates a normal assessment? (Select all that apply.) - ANS-Voice sounds are faint, muffled, and almost inaudible when the patient whispers "one, two, three" in a very soft voice; When the patient speaks in a normal voice, the examiner can hear a sound but cannot exactly distinguish what is being said; As the patient says a long "ee-ee-ee" sound, the examiner also hears a long "ee-ee-ee" sound The nurse is assessing a 65-year-old patient who has smoked a pack of cigarettes a day for the past 40 years. The nurse identifies the following findings indicating that the patient likely has emphysema: (Select all that apply.) - ANS-Costal angle greater than 90 degrees, heart sounds are muffled, decreased breath sounds with extended expirations

The nurse is assessing a 52-year-old patient admitted with aspiration pneumonia and a history of excessive alcohol consumption. The patient has been deteriorating and has developed sepsis. The nurse identifies the following findings indicating he likely has acute respiratory distress syndrome (ARDS): (Select all that apply.) - ANS-Crackles upon auscultation of lungs, blood pressure 70/50 mm Hg, very short of breath