CPA 3
The nurse is preparing to auscultate a client's lungs after completing thoracic inspection,
palpation, and percussion. How should the nurse best prepare for this assessment technique?
A. Keep the client's shirt or gown in place to maintain privacy.
B. Begin with the bell of the stethoscope on the client's anterior chest.
C. Tell the Client that you will be asking them to breathe as quickly and deeply as possible.
D. Place the diaphragm on the client's posterior chest wall. ✔✔D. Place the diaphragm on the
client's posterior chest wall.
The nurse's auscultation of a client's lung fields reveals the presence of a wheeze. The nurse
should recognize that this adventitious sound results from what pathophysiologic process?
A. Air leaking from the alveoli into the pleural space.
B. Air being diverted from the trachea to the bronchi.
C. Air increasing in turbulence in a wide passage.
D. Air passing through constricted passageways. ✔✔D. Air passing through constricted
passageways
The nurse is assessing a client's respiratory rate and rhythm during the beginning of a shift. The
client's rate is 29 breaths/min. How should the nurse respond to this assessment finding?
A. Ask the client if she has recently exerted herself.
B. Report the finding to the client's primary care provider.
C. Ask the client if she has smoked recently.
D. Palpate the client's anterior and posterior thorax. ✔✔A. Ask the client if she has recently
exerted herself.
While assessing the health of a client's respiratory system, the nurse is palpating for fremitus.
What instruction should the nurse provide to the client during this component of assessment?
A. When I say so, please exhale forcefully and hold the breath.
B. Say the letter E and keep saying it until I tell you to stop.
C. Breathe in as deeply as you can and hold your breath until I say stop.
D. Please say the number ninety-nine for me. ✔✔D. Please say the number ninety-nine for me.
The nurse is assessing a 79 year old client's posterior thorax during a focused respiratory
assessment. The nurse should attribute what assessment to old age?
A. Slight kyphosis.
The nurse is preparing to auscultate a client's lungs after completing thoracic inspection,
palpation, and percussion. How should the nurse best prepare for this assessment technique?
A. Keep the client's shirt or gown in place to maintain privacy.
B. Begin with the bell of the stethoscope on the client's anterior chest.
C. Tell the Client that you will be asking them to breathe as quickly and deeply as possible.
D. Place the diaphragm on the client's posterior chest wall. ✔✔D. Place the diaphragm on the
client's posterior chest wall.
The nurse's auscultation of a client's lung fields reveals the presence of a wheeze. The nurse
should recognize that this adventitious sound results from what pathophysiologic process?
A. Air leaking from the alveoli into the pleural space.
B. Air being diverted from the trachea to the bronchi.
C. Air increasing in turbulence in a wide passage.
D. Air passing through constricted passageways. ✔✔D. Air passing through constricted
passageways
The nurse is assessing a client's respiratory rate and rhythm during the beginning of a shift. The
client's rate is 29 breaths/min. How should the nurse respond to this assessment finding?
A. Ask the client if she has recently exerted herself.
B. Report the finding to the client's primary care provider.
C. Ask the client if she has smoked recently.
D. Palpate the client's anterior and posterior thorax. ✔✔A. Ask the client if she has recently
exerted herself.
While assessing the health of a client's respiratory system, the nurse is palpating for fremitus.
What instruction should the nurse provide to the client during this component of assessment?
A. When I say so, please exhale forcefully and hold the breath.
B. Say the letter E and keep saying it until I tell you to stop.
C. Breathe in as deeply as you can and hold your breath until I say stop.
D. Please say the number ninety-nine for me. ✔✔D. Please say the number ninety-nine for me.
The nurse is assessing a 79 year old client's posterior thorax during a focused respiratory
assessment. The nurse should attribute what assessment to old age?
A. Slight kyphosis.
