NR 603 Week 2 Case Discussion
Pulmonary Part One
Comprehensive Examination — 105 Questions
Advanced Clinical Diagnosis and Practice Across the Lifespan
Updated Spring 2026/2027 | Chamberlain University MSN Curriculum | NR 603 Advanced Clinical Diagnosis and
Practice Across the Lifespan
Exam Structure: 105 multiple-choice questions across 7 sections covering pulmonary anatomy/assessment,
obstructive disorders, restrictive/infectious disorders, vascular/pleural disorders, diagnostic testing,
pharmacological management, and case discussion application.
Cognitive Distribution: 30% recall, 50% application, 20% analysis — aligned with graduate-level advanced
practice nursing competencies.
Format: Each question presents a clinical scenario or recall stem, four options (A–D) with one correct answer,
and a detailed rationale grounded in current evidence-based guidelines (GINA 2026, GOLD 2026, ATS/IDSA
2026, CHEST 2026).
Curricular Alignment: Chamberlain University MSN NR 603 Week 2 case discussion expectations —
differential diagnosis, clinical reasoning, SOAP documentation, ICD-10 coding, and interprofessional
collaboration.
SECTION 1: Pulmonary Anatomy, Physiology, and Assessment
Questions Q1–Q15 | Airway Structures, Gas Exchange, & Respiratory Assessment Techniques
Q1: A 34-year-old patient presents for a routine physical. During upper airway assessment, the advanced
practice nurse understands that the structure separating the oropharynx from the nasopharynx and
preventing nasal regurgitation during swallowing is the:
A. Epiglottis
B. Soft palate [CORRECT]
C. Hard palate
D. Vocal cords
Correct Answer: B
Rationale:
The soft palate, composed of the uvula and palatopharyngeal arch, elevates during swallowing to separate the
nasopharynx from the oropharynx, preventing nasal regurgitation. The epiglottis covers the laryngeal inlet to protect the
trachea from aspiration. The hard palate is a fixed bony structure with no mobility. The vocal cords reside in the larynx
and are involved in phonation and airway protection, not nasopharyngeal separation.
Page 1 | Chamberlain University MSN Program | Advanced Clinical Diagnosis & Practice Across the Lifespan
,NR 603 Week 2 Case Discussion: Pulmonary Part One Updated Spring 2026/2027
Q2: A 28-year-old patient with no pulmonary history is being evaluated for dyspnea. The APRN recalls
that the primary site of gas exchange in the adult lung is the:
A. Terminal bronchioles
B. Respiratory bronchioles
C. Alveolar-capillary membrane [CORRECT]
D. Pulmonary arterioles
Correct Answer: C
Rationale:
Gas exchange occurs across the alveolar-capillary membrane, where type I pneumocytes and capillary endothelial cells
form a thin diffusion barrier (~0.5 µm) allowing O2 and CO2 exchange via partial pressure gradients. Terminal
bronchioles are purely conducting airways with no gas exchange. Respiratory bronchioles participate minimally in gas
exchange and mark the transition zone. Pulmonary arterioles deliver deoxygenated blood but do not perform gas
exchange themselves.
Q3: During inspection of a 68-year-old patient with known COPD, the APRN observes a barrel chest, use
of accessory muscles, and pursed-lip breathing. Which physiological mechanism best explains pursed-lip
breathing in this patient?
A. It increases airway pressure during exhalation to prevent small airway collapse [CORRECT]
B. It decreases work of breathing by reducing tidal volume
C. It shifts gas exchange to the upper lobes
D. It increases inspiratory flow rate
Correct Answer: A
Rationale:
Pursed-lip breathing creates positive end-expiratory pressure (PEEP-like effect) that stents small airways open during
exhalation, preventing premature airway collapse and air trapping — a hallmark of COPD. This improves
ventilation-perfusion matching and reduces dyspnea. It does not reduce tidal volume; in fact, it often slows exhalation to
allow more complete emptying. Gas exchange is not selectively shifted to upper lobes, and the technique targets
expiratory, not inspiratory, flow.
Q4: A 55-year-old with suspected left lower lobe pneumonia is being assessed. On palpation, the APRN
notes decreased tactile fremitus over the left lower lobe. Which condition best explains this finding?
A. Consolidation from bacterial pneumonia
B. Pleural effusion covering the lung parenchyma [CORRECT]
C. Pulmonary fibrosis
D. Atelectasis with collapsed alveoli
Correct Answer: B
Rationale:
Tactile fremitus decreases when sound transmission is impaired by fluid or air in the pleural space (effusion,
pneumothorax), bronchial obstruction, or hyperinflation (COPD). A pleural effusion interposes fluid between the lung
and chest wall, dampening vibration. Consolidation from pneumonia typically increases fremitus because dense,
fluid-filled lung transmits vibrations better. Pulmonary fibrosis may increase fremitus. Atelectasis with patent airways
can increase fremitus, though complete obstruction decreases it.
Q5: While percussing the chest of a 72-year-old with chronic heart failure, the APRN elicits a dull note
over the right lower lobe field. The most likely underlying finding is:
A. Pneumothorax
B. Severe emphysema with hyperinflation
Page 2 | Chamberlain University MSN Program | Advanced Clinical Diagnosis & Practice Across the Lifespan
,NR 603 Week 2 Case Discussion: Pulmonary Part One Updated Spring 2026/2027
C. Pleural effusion or consolidation [CORRECT]
D. Normal lung parenchyma
Correct Answer: C
Rationale:
A dull percussion note indicates increased tissue density or fluid in the pleural space — most commonly pleural
effusion, consolidation (pneumonia), atelectasis, or a solid mass. In a CHF patient, right-sided pleural effusion is
particularly common due to preferential fluid tracking. Pneumothorax and emphysema produce hyperresonance due to
increased air. Normal lung yields resonance, not dullness.
Q6: An APRN is auscultating a healthy 25-year-old patient and notes soft, low-pitched breath sounds over
the peripheral lung fields with a longer inspiratory than expiratory phase. These sounds are correctly
documented as:
A. Bronchial breath sounds
B. Bronchovesicular breath sounds
C. Vesicular breath sounds [CORRECT]
D. Tracheal breath sounds
Correct Answer: C
Rationale:
Vesicular breath sounds are heard over peripheral lung fields, are soft and low-pitched, and have a 3:1
inspiratory-to-expiratory ratio because expiration is normally passive and brief. Bronchial breath sounds are loud,
high-pitched, with a longer expiratory phase, heard over the manubrium — but considered abnormal (consolidation)
when heard peripherally. Bronchovesicular sounds are intermediate, heard over the mainstem bronchi. Tracheal sounds
are harsh and loud, heard only over the trachea.
Q7: A 70-year-old with heart failure presents with worsening dyspnea. On auscultation, the APRN hears
discontinuous, brief, popping sounds that do not clear with coughing, heard best at end-inspiration over
the bilateral lung bases. The APRN documents these as:
A. Fine crackles secondary to interstitial fluid [CORRECT]
B. Coarse crackles from secretions in large airways
C. Pleural friction rub
D. Wheezes from bronchospasm
Correct Answer: A
Rationale:
Fine crackles are brief, discontinuous, late-inspiratory sounds caused by sudden opening of collapsed small airways and
alveoli — classic in interstitial edema from heart failure, pulmonary fibrosis, or early pneumonia. They do not clear with
cough. Coarse crackles are louder, lower-pitched, earlier in inspiration, and often clear with coughing, indicating
secretions in larger airways (bronchitis, bronchiectasis). Pleural friction rub is a grating, leathery sound throughout
respiration. Wheezes are continuous, musical sounds from bronchospasm.
Q8: A 42-year-old with asthma presents with diffuse, high-pitched, continuous musical sounds heard
throughout expiration. The APRN understands these wheezes are generated by which mechanism?
A. Fluid in the alveolar spaces vibrating during breathing
B. High-velocity airflow through narrowed small airways due to bronchospasm and inflammation
[CORRECT]
C. Pleural inflammation causing the visceral and parietal pleura to rub
D. Sudden equalization of pressure in collapsed alveoli
Correct Answer: B
Page 3 | Chamberlain University MSN Program | Advanced Clinical Diagnosis & Practice Across the Lifespan
, NR 603 Week 2 Case Discussion: Pulmonary Part One Updated Spring 2026/2027
Rationale:
Wheezes are continuous, musical sounds produced when air flows rapidly through narrowed small airways due to
bronchospasm, mucosal edema, or secretions — pathognomonic of asthma and COPD exacerbations. They are an
expiratory phenomenon due to dynamic airway compression. Fluid in alveoli causes crackles, not wheezes. Pleural
inflammation produces a friction rub. Sudden alveolar opening produces crackles, not wheezes.
Q9: A 3-year-old child is brought to the clinic with acute onset of stridor, drooling, and fever. The child is
sitting forward in a tripod position. The APRN's priority action is to:
A. Perform a thorough oropharyngeal examination to confirm epiglottitis
B. Keep the child calm, avoid invasive examination, and arrange emergent transfer for airway
management [CORRECT]
C. Administer nebulized albuterol to relieve bronchospasm
D. Obtain a chest radiograph in the radiology department immediately
Correct Answer: B
Rationale:
Stridor with drooling, fever, and tripod posture is classic for epiglottitis — a true airway emergency. ANY agitation,
tongue blade examination, or invasive procedure can trigger complete airway obstruction. Priority is keeping the child
calm, providing humidified oxygen if tolerated, and emergent transfer to an ICU setting with anesthesia/ENT for
controlled airway management. Albuterol does not address supraglottic obstruction. Transporting the child
unaccompanied to radiology is unsafe.
Q10: An 81-year-old patient with severe emphysema is admitted with dyspnea. Inspection reveals
prominent use of sternocleidomastoid and scalene muscles during inspiration. The APRN interprets this
finding as:
A. A normal finding in the elderly
B. Indicative of impending respiratory failure requiring ICU-level monitoring [CORRECT]
C. Suggestive of neuromuscular weakness
D. A sign of metabolic alkalosis
Correct Answer: B
Rationale:
Accessory muscle use (sternocleidomastoid, scalenes, intercostals) indicates significantly increased work of breathing
and is an ominous sign in COPD, often signaling impending respiratory failure. The diaphragm is flattened and
dysfunctional in emphysema, forcing recruitment of accessory muscles. This is never normal in any age group.
Neuromuscular weakness would cause paradoxical breathing or weak cough, not accessory recruitment. It is unrelated to
metabolic alkalosis.
Q11: A 60-year-old patient is being evaluated for diaphragmatic excursion. The APRN percusses during
full expiration and again at full inspiration, measuring the distance the lower border of lung resonance
moves. A normal diaphragmatic excursion is approximately:
A. 1–2 cm bilaterally
B. 3–5 cm bilaterally in adults (up to 5–6 cm in athletic individuals) [CORRECT]
C. 7–10 cm bilaterally
D. Asymmetric with the right side 2 cm greater than the left
Correct Answer: B
Rationale:
Normal diaphragmatic excursion is 3–5 cm bilaterally (up to 5–6 cm in well-conditioned individuals), measured as the
distance between the levels of dullness at full expiration and full inspiration. Reduced excursion suggests phrenic nerve
palsy, pleural effusion, atelectasis, or restrictive disease. 1–2 cm is abnormally reduced. 7–10 cm exceeds normal
Page 4 | Chamberlain University MSN Program | Advanced Clinical Diagnosis & Practice Across the Lifespan
Pulmonary Part One
Comprehensive Examination — 105 Questions
Advanced Clinical Diagnosis and Practice Across the Lifespan
Updated Spring 2026/2027 | Chamberlain University MSN Curriculum | NR 603 Advanced Clinical Diagnosis and
Practice Across the Lifespan
Exam Structure: 105 multiple-choice questions across 7 sections covering pulmonary anatomy/assessment,
obstructive disorders, restrictive/infectious disorders, vascular/pleural disorders, diagnostic testing,
pharmacological management, and case discussion application.
Cognitive Distribution: 30% recall, 50% application, 20% analysis — aligned with graduate-level advanced
practice nursing competencies.
Format: Each question presents a clinical scenario or recall stem, four options (A–D) with one correct answer,
and a detailed rationale grounded in current evidence-based guidelines (GINA 2026, GOLD 2026, ATS/IDSA
2026, CHEST 2026).
Curricular Alignment: Chamberlain University MSN NR 603 Week 2 case discussion expectations —
differential diagnosis, clinical reasoning, SOAP documentation, ICD-10 coding, and interprofessional
collaboration.
SECTION 1: Pulmonary Anatomy, Physiology, and Assessment
Questions Q1–Q15 | Airway Structures, Gas Exchange, & Respiratory Assessment Techniques
Q1: A 34-year-old patient presents for a routine physical. During upper airway assessment, the advanced
practice nurse understands that the structure separating the oropharynx from the nasopharynx and
preventing nasal regurgitation during swallowing is the:
A. Epiglottis
B. Soft palate [CORRECT]
C. Hard palate
D. Vocal cords
Correct Answer: B
Rationale:
The soft palate, composed of the uvula and palatopharyngeal arch, elevates during swallowing to separate the
nasopharynx from the oropharynx, preventing nasal regurgitation. The epiglottis covers the laryngeal inlet to protect the
trachea from aspiration. The hard palate is a fixed bony structure with no mobility. The vocal cords reside in the larynx
and are involved in phonation and airway protection, not nasopharyngeal separation.
Page 1 | Chamberlain University MSN Program | Advanced Clinical Diagnosis & Practice Across the Lifespan
,NR 603 Week 2 Case Discussion: Pulmonary Part One Updated Spring 2026/2027
Q2: A 28-year-old patient with no pulmonary history is being evaluated for dyspnea. The APRN recalls
that the primary site of gas exchange in the adult lung is the:
A. Terminal bronchioles
B. Respiratory bronchioles
C. Alveolar-capillary membrane [CORRECT]
D. Pulmonary arterioles
Correct Answer: C
Rationale:
Gas exchange occurs across the alveolar-capillary membrane, where type I pneumocytes and capillary endothelial cells
form a thin diffusion barrier (~0.5 µm) allowing O2 and CO2 exchange via partial pressure gradients. Terminal
bronchioles are purely conducting airways with no gas exchange. Respiratory bronchioles participate minimally in gas
exchange and mark the transition zone. Pulmonary arterioles deliver deoxygenated blood but do not perform gas
exchange themselves.
Q3: During inspection of a 68-year-old patient with known COPD, the APRN observes a barrel chest, use
of accessory muscles, and pursed-lip breathing. Which physiological mechanism best explains pursed-lip
breathing in this patient?
A. It increases airway pressure during exhalation to prevent small airway collapse [CORRECT]
B. It decreases work of breathing by reducing tidal volume
C. It shifts gas exchange to the upper lobes
D. It increases inspiratory flow rate
Correct Answer: A
Rationale:
Pursed-lip breathing creates positive end-expiratory pressure (PEEP-like effect) that stents small airways open during
exhalation, preventing premature airway collapse and air trapping — a hallmark of COPD. This improves
ventilation-perfusion matching and reduces dyspnea. It does not reduce tidal volume; in fact, it often slows exhalation to
allow more complete emptying. Gas exchange is not selectively shifted to upper lobes, and the technique targets
expiratory, not inspiratory, flow.
Q4: A 55-year-old with suspected left lower lobe pneumonia is being assessed. On palpation, the APRN
notes decreased tactile fremitus over the left lower lobe. Which condition best explains this finding?
A. Consolidation from bacterial pneumonia
B. Pleural effusion covering the lung parenchyma [CORRECT]
C. Pulmonary fibrosis
D. Atelectasis with collapsed alveoli
Correct Answer: B
Rationale:
Tactile fremitus decreases when sound transmission is impaired by fluid or air in the pleural space (effusion,
pneumothorax), bronchial obstruction, or hyperinflation (COPD). A pleural effusion interposes fluid between the lung
and chest wall, dampening vibration. Consolidation from pneumonia typically increases fremitus because dense,
fluid-filled lung transmits vibrations better. Pulmonary fibrosis may increase fremitus. Atelectasis with patent airways
can increase fremitus, though complete obstruction decreases it.
Q5: While percussing the chest of a 72-year-old with chronic heart failure, the APRN elicits a dull note
over the right lower lobe field. The most likely underlying finding is:
A. Pneumothorax
B. Severe emphysema with hyperinflation
Page 2 | Chamberlain University MSN Program | Advanced Clinical Diagnosis & Practice Across the Lifespan
,NR 603 Week 2 Case Discussion: Pulmonary Part One Updated Spring 2026/2027
C. Pleural effusion or consolidation [CORRECT]
D. Normal lung parenchyma
Correct Answer: C
Rationale:
A dull percussion note indicates increased tissue density or fluid in the pleural space — most commonly pleural
effusion, consolidation (pneumonia), atelectasis, or a solid mass. In a CHF patient, right-sided pleural effusion is
particularly common due to preferential fluid tracking. Pneumothorax and emphysema produce hyperresonance due to
increased air. Normal lung yields resonance, not dullness.
Q6: An APRN is auscultating a healthy 25-year-old patient and notes soft, low-pitched breath sounds over
the peripheral lung fields with a longer inspiratory than expiratory phase. These sounds are correctly
documented as:
A. Bronchial breath sounds
B. Bronchovesicular breath sounds
C. Vesicular breath sounds [CORRECT]
D. Tracheal breath sounds
Correct Answer: C
Rationale:
Vesicular breath sounds are heard over peripheral lung fields, are soft and low-pitched, and have a 3:1
inspiratory-to-expiratory ratio because expiration is normally passive and brief. Bronchial breath sounds are loud,
high-pitched, with a longer expiratory phase, heard over the manubrium — but considered abnormal (consolidation)
when heard peripherally. Bronchovesicular sounds are intermediate, heard over the mainstem bronchi. Tracheal sounds
are harsh and loud, heard only over the trachea.
Q7: A 70-year-old with heart failure presents with worsening dyspnea. On auscultation, the APRN hears
discontinuous, brief, popping sounds that do not clear with coughing, heard best at end-inspiration over
the bilateral lung bases. The APRN documents these as:
A. Fine crackles secondary to interstitial fluid [CORRECT]
B. Coarse crackles from secretions in large airways
C. Pleural friction rub
D. Wheezes from bronchospasm
Correct Answer: A
Rationale:
Fine crackles are brief, discontinuous, late-inspiratory sounds caused by sudden opening of collapsed small airways and
alveoli — classic in interstitial edema from heart failure, pulmonary fibrosis, or early pneumonia. They do not clear with
cough. Coarse crackles are louder, lower-pitched, earlier in inspiration, and often clear with coughing, indicating
secretions in larger airways (bronchitis, bronchiectasis). Pleural friction rub is a grating, leathery sound throughout
respiration. Wheezes are continuous, musical sounds from bronchospasm.
Q8: A 42-year-old with asthma presents with diffuse, high-pitched, continuous musical sounds heard
throughout expiration. The APRN understands these wheezes are generated by which mechanism?
A. Fluid in the alveolar spaces vibrating during breathing
B. High-velocity airflow through narrowed small airways due to bronchospasm and inflammation
[CORRECT]
C. Pleural inflammation causing the visceral and parietal pleura to rub
D. Sudden equalization of pressure in collapsed alveoli
Correct Answer: B
Page 3 | Chamberlain University MSN Program | Advanced Clinical Diagnosis & Practice Across the Lifespan
, NR 603 Week 2 Case Discussion: Pulmonary Part One Updated Spring 2026/2027
Rationale:
Wheezes are continuous, musical sounds produced when air flows rapidly through narrowed small airways due to
bronchospasm, mucosal edema, or secretions — pathognomonic of asthma and COPD exacerbations. They are an
expiratory phenomenon due to dynamic airway compression. Fluid in alveoli causes crackles, not wheezes. Pleural
inflammation produces a friction rub. Sudden alveolar opening produces crackles, not wheezes.
Q9: A 3-year-old child is brought to the clinic with acute onset of stridor, drooling, and fever. The child is
sitting forward in a tripod position. The APRN's priority action is to:
A. Perform a thorough oropharyngeal examination to confirm epiglottitis
B. Keep the child calm, avoid invasive examination, and arrange emergent transfer for airway
management [CORRECT]
C. Administer nebulized albuterol to relieve bronchospasm
D. Obtain a chest radiograph in the radiology department immediately
Correct Answer: B
Rationale:
Stridor with drooling, fever, and tripod posture is classic for epiglottitis — a true airway emergency. ANY agitation,
tongue blade examination, or invasive procedure can trigger complete airway obstruction. Priority is keeping the child
calm, providing humidified oxygen if tolerated, and emergent transfer to an ICU setting with anesthesia/ENT for
controlled airway management. Albuterol does not address supraglottic obstruction. Transporting the child
unaccompanied to radiology is unsafe.
Q10: An 81-year-old patient with severe emphysema is admitted with dyspnea. Inspection reveals
prominent use of sternocleidomastoid and scalene muscles during inspiration. The APRN interprets this
finding as:
A. A normal finding in the elderly
B. Indicative of impending respiratory failure requiring ICU-level monitoring [CORRECT]
C. Suggestive of neuromuscular weakness
D. A sign of metabolic alkalosis
Correct Answer: B
Rationale:
Accessory muscle use (sternocleidomastoid, scalenes, intercostals) indicates significantly increased work of breathing
and is an ominous sign in COPD, often signaling impending respiratory failure. The diaphragm is flattened and
dysfunctional in emphysema, forcing recruitment of accessory muscles. This is never normal in any age group.
Neuromuscular weakness would cause paradoxical breathing or weak cough, not accessory recruitment. It is unrelated to
metabolic alkalosis.
Q11: A 60-year-old patient is being evaluated for diaphragmatic excursion. The APRN percusses during
full expiration and again at full inspiration, measuring the distance the lower border of lung resonance
moves. A normal diaphragmatic excursion is approximately:
A. 1–2 cm bilaterally
B. 3–5 cm bilaterally in adults (up to 5–6 cm in athletic individuals) [CORRECT]
C. 7–10 cm bilaterally
D. Asymmetric with the right side 2 cm greater than the left
Correct Answer: B
Rationale:
Normal diaphragmatic excursion is 3–5 cm bilaterally (up to 5–6 cm in well-conditioned individuals), measured as the
distance between the levels of dullness at full expiration and full inspiration. Reduced excursion suggests phrenic nerve
palsy, pleural effusion, atelectasis, or restrictive disease. 1–2 cm is abnormally reduced. 7–10 cm exceeds normal
Page 4 | Chamberlain University MSN Program | Advanced Clinical Diagnosis & Practice Across the Lifespan
