Chapter 27 Assessment: Respiratory System: Lewis’s Medical-
Surgical Nursing Questions with Answers (100% Correct
Answers)
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 for complete a full physical assessment.
b. Complete the health history and check for allergies before treatment.
c. Briefly ask specific questions about this episode of respiratory distress.
d. Delay the physical assessment to first complete pulmonary function tests. —Answer: ANS: C
If respiratory distress is severe, only obtain pertinent information and defer a thorough
assessment until the patient's condition stabilizes. 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.
2. The nurse prepares a patient who has a left-sided pleural effusion for a thoracentesis. How
should the nurse position the patient?
a. High-Fowler's position with the left arm extended
b. Supine with the head of the bed elevated 30 degrees
c. On the right side with the left arm extended above the head
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, d. Sitting upright with the arms supported on an over bed table —Answer: ANS: 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.
3. The arterial blood gas (ABG) results of a patient with diabetes show metabolic acidosis.
Which compensatory finding would the nurse expect?
a. Intercostal retractions
b. Kussmaul respirations
c. Low oxygen saturation (SpO2)
d. Decreased venous O2 pressure —Answer: ANS: B
Kussmaul (deep and rapid) respirations are a compensatory mechanism for metabolic acidosis.
Acidosis does not cause intercostal retractions, a low oxygen saturation rate, or a decrease in
venous O2 pressure.
4. On auscultation of a patient's lungs, the nurse hears low-pitched, bubbling sounds during
inhalation in the lower third bilaterally. 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 theright and left lower lobes —Answer: ANS: A
© 2025 All rights reserved
Surgical Nursing Questions with Answers (100% Correct
Answers)
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 for complete a full physical assessment.
b. Complete the health history and check for allergies before treatment.
c. Briefly ask specific questions about this episode of respiratory distress.
d. Delay the physical assessment to first complete pulmonary function tests. —Answer: ANS: C
If respiratory distress is severe, only obtain pertinent information and defer a thorough
assessment until the patient's condition stabilizes. 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.
2. The nurse prepares a patient who has a left-sided pleural effusion for a thoracentesis. How
should the nurse position the patient?
a. High-Fowler's position with the left arm extended
b. Supine with the head of the bed elevated 30 degrees
c. On the right side with the left arm extended above the head
© 2025 All rights reserved
, d. Sitting upright with the arms supported on an over bed table —Answer: ANS: 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.
3. The arterial blood gas (ABG) results of a patient with diabetes show metabolic acidosis.
Which compensatory finding would the nurse expect?
a. Intercostal retractions
b. Kussmaul respirations
c. Low oxygen saturation (SpO2)
d. Decreased venous O2 pressure —Answer: ANS: B
Kussmaul (deep and rapid) respirations are a compensatory mechanism for metabolic acidosis.
Acidosis does not cause intercostal retractions, a low oxygen saturation rate, or a decrease in
venous O2 pressure.
4. On auscultation of a patient's lungs, the nurse hears low-pitched, bubbling sounds during
inhalation in the lower third bilaterally. 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 theright and left lower lobes —Answer: ANS: A
© 2025 All rights reserved
