3MED SURG 201 WEEKS 5 AND 6 QUIZZES
Chapter 26: Nursing Assessment: 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.The nurse prepares a patient with a left-sided pleural effusion for a thoracentesis. How should the nurse position the patient?
a.Supine with the head of the bed elevated 30 degrees
b.In a high-Fowler’s position with the left arm extended
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; HCO – 18 mEq/L. The nurse would expect which finding?
a.Intercostal retractions b.Kussmaul respirations
c.Low oxygen saturation (SpO2)
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 has a bronchoscopy. After the procedure, which intervention by
the nurse is most appropriate?
a.Elevate the head of the bed to 80 to 90 degrees.
b.Keep the patient NPO until the gag reflex returns.
c.Place on bed rest for at least 4 hours after bronchoscopy.
d.Notify the health care provider about blood-tinged mucus.
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 heard on inspiration
d.A series of long-duration, discontinuous, low-pitched sounds during inspiration 8.While caring for a patient with respiratory disease, the nurse observes that the patient’s SpO 2 drops from 93% to 88% while the patient is ambulating in the hallway. What is the priority action of the nurse?
a.Notify the health care provider.
b.Document the response to exercise.
c.
d.Encourage the patient to pace activity.
9.The nurse teaches a patient about pulmonary function testing (PFT). Which statement, if made by the patient, indicates teaching was effective?
a.“I will use my inhaler right before the test.”
b.“I won’t eat or drink anything 8 hours before the test.”
c.“I should inhale deeply and blow out as hard as I can during the test.”
d.“My blood pressure and pulse will be checked every 15 minutes after the test.”
10.The nurse observes a student who is listening to a patient’s lungs who is having no problems with breathing. Which action by the student indicates a need to review respiratory assessment skills?
a.The student starts at the apices of the lungs and moves to the bases.Administer the PRN supplemental O2.
Chapter 26: Nursing Assessment: 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.The nurse prepares a patient with a left-sided pleural effusion for a thoracentesis. How should the nurse position the patient?
a.Supine with the head of the bed elevated 30 degrees
b.In a high-Fowler’s position with the left arm extended
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; HCO – 18 mEq/L. The nurse would expect which finding?
a.Intercostal retractions b.Kussmaul respirations
c.Low oxygen saturation (SpO2)
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 has a bronchoscopy. After the procedure, which intervention by
the nurse is most appropriate?
a.Elevate the head of the bed to 80 to 90 degrees.
b.Keep the patient NPO until the gag reflex returns.
c.Place on bed rest for at least 4 hours after bronchoscopy.
d.Notify the health care provider about blood-tinged mucus.
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 heard on inspiration
d.A series of long-duration, discontinuous, low-pitched sounds during inspiration 8.While caring for a patient with respiratory disease, the nurse observes that the patient’s SpO 2 drops from 93% to 88% while the patient is ambulating in the hallway. What is the priority action of the nurse?
a.Notify the health care provider.
b.Document the response to exercise.
c.
d.Encourage the patient to pace activity.
9.The nurse teaches a patient about pulmonary function testing (PFT). Which statement, if made by the patient, indicates teaching was effective?
a.“I will use my inhaler right before the test.”
b.“I won’t eat or drink anything 8 hours before the test.”
c.“I should inhale deeply and blow out as hard as I can during the test.”
d.“My blood pressure and pulse will be checked every 15 minutes after the test.”
10.The nurse observes a student who is listening to a patient’s lungs who is having no problems with breathing. Which action by the student indicates a need to review respiratory assessment skills?
a.The student starts at the apices of the lungs and moves to the bases.Administer the PRN supplemental O2.
