Exam 1 Test Bank
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. - ✔✔ correct answer B
When a patient has severe respiratory distress, only information pertinent to the current episode is
obtained, and a more thorough assessment is deferred until later. Obtaining a comprehensive health
history or full physical examination is unnecessary until the acute distress has resolved. Brief
questioning and a focused physical assessment should be done rapidly to help determine the cause
of the distress and suggest treatment. Checking for allergies is important, but it is not appropriate to
complete the entire admission database at this time. The initial respiratory assessment must be
completed before any diagnostic tests or interventions can be ordered.
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-Fowlers 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 - ✔✔ correct answer D
The upright position with the arms supported increases lung expansion, allows fluid to collect at the
lung bases, and expands the intercostal space so that access to the pleural space is easier.
The other positions would increase the work of breathing for the patient and make it more difficult
for the health care provider performing the thoracentesis.
.
A diabetic patients arterial blood gas (ABG) results are pH 7.28; PaCO2 34 mm Hg; PaO2 85 mm Hg;
HCO3 18 mEq/L. The nurse would expect which finding?
,Exam 1 Test Bank
a. Intercostal retractions
b. Kussmaul respirations
c. Low oxygen saturation (SpO2)
d. Decreased venous O2 pressure - ✔✔ correct answer B
Kussmaul (deep and rapid) respirations are a compensatory mechanism for metabolic acidosis. The
low pH and low bicarbonate result indicate metabolic acidosis.
Intercostal retractions, a low oxygen saturation rate, and a decrease in venous O2 pressure would not
be caused by acidosis.
On auscultation of a patients 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 - ✔✔ correct answer A
Crackles are low-pitched, bubbling sounds usually heard on inspiration.
- Wheezes are high-pitched sounds. They can be heard during the expiratory or inspiratory phase of
the respiratory cycle.
- The lower third of both lungs are the bases, not apices.
- Pleural friction rubs are grating sounds that are usually heard during both inspiration and
expiration.
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.
,Exam 1 Test Bank
d. Auscultate anterior and posterior breath sounds bilaterally. - ✔✔ correct answer D
To assess for tactile fremitus, the nurse should use the palms of the hands to assess for vibration
when the patient repeats a word or phrase such as 99. After noting absent fremitus, the nurse should
then auscultate the lungs to assess for the presence or absence of breath sounds. Absent fremitus
may be noted with pneumothorax or atelectasis. The vibration is increased in conditions such as
pneumonia, lung tumors, thick bronchial secretions, and pleural effusion.
Turning, coughing, and deep breathing is an appropriate intervention for atelectasis, but the nurse
needs to first assess breath sounds. Fremitus is decreased if the hand is farther from the lung or the
lung is hyperinflated (barrel chest).The anterior of the chest is more difficult to palpate for fremitus
because of the presence of large muscles and breast tissue.
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. - ✔✔ correct answer B
Risk for aspiration and maintaining an open airway is the priority. Because a local anesthetic is used
to suppress the gag/cough reflexes during bronchoscopy, the nurse should monitor for the return of
these reflexes before allowing the patient to take oral fluids or food.
Blood-tinged mucus is not uncommon after bronchoscopy. The patient does not need to be on bed
rest, and the head of the bed does not need to be in the high-Fowlers position.
The nurse completes a shift assessment on a patient admitted in the early phase of heart failure.
When auscultating the patients 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
, Exam 1 Test Bank
d. A series of long-duration, discontinuous, low-pitched sounds during inspiration - ✔✔ correct
answer C
Fine crackles are likely to be heard in the early phase of heart failure. Fine crackles are discontinuous,
high- pitched sounds of short duration heard on inspiration.
.
.
While caring for a patient with respiratory disease, the nurse observes that the patients SpO2 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. Administer the PRN supplemental O2.
d. Encourage the patient to pace activity. - ✔✔ correct answer C
The drop in SpO2 to 85% indicates that the patient is hypoxemic and needs supplemental oxygen
when exercising.
The other actions are also important, but the first action should be to correct the hypoxemia.
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 wont 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. - ✔✔ correct answer
C
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. - ✔✔ correct answer B
When a patient has severe respiratory distress, only information pertinent to the current episode is
obtained, and a more thorough assessment is deferred until later. Obtaining a comprehensive health
history or full physical examination is unnecessary until the acute distress has resolved. Brief
questioning and a focused physical assessment should be done rapidly to help determine the cause
of the distress and suggest treatment. Checking for allergies is important, but it is not appropriate to
complete the entire admission database at this time. The initial respiratory assessment must be
completed before any diagnostic tests or interventions can be ordered.
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-Fowlers 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 - ✔✔ correct answer D
The upright position with the arms supported increases lung expansion, allows fluid to collect at the
lung bases, and expands the intercostal space so that access to the pleural space is easier.
The other positions would increase the work of breathing for the patient and make it more difficult
for the health care provider performing the thoracentesis.
.
A diabetic patients arterial blood gas (ABG) results are pH 7.28; PaCO2 34 mm Hg; PaO2 85 mm Hg;
HCO3 18 mEq/L. The nurse would expect which finding?
,Exam 1 Test Bank
a. Intercostal retractions
b. Kussmaul respirations
c. Low oxygen saturation (SpO2)
d. Decreased venous O2 pressure - ✔✔ correct answer B
Kussmaul (deep and rapid) respirations are a compensatory mechanism for metabolic acidosis. The
low pH and low bicarbonate result indicate metabolic acidosis.
Intercostal retractions, a low oxygen saturation rate, and a decrease in venous O2 pressure would not
be caused by acidosis.
On auscultation of a patients 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 - ✔✔ correct answer A
Crackles are low-pitched, bubbling sounds usually heard on inspiration.
- Wheezes are high-pitched sounds. They can be heard during the expiratory or inspiratory phase of
the respiratory cycle.
- The lower third of both lungs are the bases, not apices.
- Pleural friction rubs are grating sounds that are usually heard during both inspiration and
expiration.
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.
,Exam 1 Test Bank
d. Auscultate anterior and posterior breath sounds bilaterally. - ✔✔ correct answer D
To assess for tactile fremitus, the nurse should use the palms of the hands to assess for vibration
when the patient repeats a word or phrase such as 99. After noting absent fremitus, the nurse should
then auscultate the lungs to assess for the presence or absence of breath sounds. Absent fremitus
may be noted with pneumothorax or atelectasis. The vibration is increased in conditions such as
pneumonia, lung tumors, thick bronchial secretions, and pleural effusion.
Turning, coughing, and deep breathing is an appropriate intervention for atelectasis, but the nurse
needs to first assess breath sounds. Fremitus is decreased if the hand is farther from the lung or the
lung is hyperinflated (barrel chest).The anterior of the chest is more difficult to palpate for fremitus
because of the presence of large muscles and breast tissue.
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. - ✔✔ correct answer B
Risk for aspiration and maintaining an open airway is the priority. Because a local anesthetic is used
to suppress the gag/cough reflexes during bronchoscopy, the nurse should monitor for the return of
these reflexes before allowing the patient to take oral fluids or food.
Blood-tinged mucus is not uncommon after bronchoscopy. The patient does not need to be on bed
rest, and the head of the bed does not need to be in the high-Fowlers position.
The nurse completes a shift assessment on a patient admitted in the early phase of heart failure.
When auscultating the patients 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
, Exam 1 Test Bank
d. A series of long-duration, discontinuous, low-pitched sounds during inspiration - ✔✔ correct
answer C
Fine crackles are likely to be heard in the early phase of heart failure. Fine crackles are discontinuous,
high- pitched sounds of short duration heard on inspiration.
.
.
While caring for a patient with respiratory disease, the nurse observes that the patients SpO2 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. Administer the PRN supplemental O2.
d. Encourage the patient to pace activity. - ✔✔ correct answer C
The drop in SpO2 to 85% indicates that the patient is hypoxemic and needs supplemental oxygen
when exercising.
The other actions are also important, but the first action should be to correct the hypoxemia.
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 wont 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. - ✔✔ correct answer
C
