Assessing The Respiratory System Full Test Bank Chapter 34 - Medical Surgical Nursing 7e | Test Bank by LeMone, Burke, Bauldoff by LeMone, Burke, Gerene Bauldoff. DOCX document preview.
LeMone & Burke's Medical-Surgical Nursing, 7e (Bauldoff/Gubrud/Carno)
Chapter 34 Assessing the Respiratory System
1) The nurse observes a patient breathing through an open mouth. Which function is being bypassed by mouth breathing?
1. Cooling the air
2. Neutralizing the air
3. Filtering the air
4. Separating the air
Page Ref: 1217
Cognitive Level: Analyzing
Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 34.1 Describe the anatomy, physiology, and functions of the nose and sinuses, pharynx, larynx, trachea, lungs, pleura, bronchi and alveoli, and rib cage and intercostal muscles, and identify abnormal findings that may indicate impairment of the respiratory system.
MNL Learning Outcome: 2. Recognize normal findings of the respiratory system collected during assessment and health promotion activities to support the health of this body system.
2) The nurse notes that a patient with a head cold has a change in speech tone and volume. What should the nurse consider as being the reason for this observation?
1. The patient has been sneezing because of the cold.
2. The patient has been coughing because of the cold.
3. The cold is raising the patient's body temperature.
4. The sinuses play a role in speech.
Page Ref: 1217
Cognitive Level: Analyzing
Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 34.1 Describe the anatomy, physiology, and functions of the nose and sinuses, pharynx, larynx, trachea, lungs, pleura, bronchi and alveoli, and rib cage and intercostal muscles, and identify abnormal findings that may indicate impairment of the respiratory system.
MNL Learning Outcome: 3. Interpret abnormal findings of the respiratory system collected during assessment.
3) A patient is diagnosed with a middle ear infection. Which portion of the patient's airway is affected?
1. Nasopharynx
2. Oropharynx
3. Laryngopharynx
4. Nares
Page Ref: 1217
Cognitive Level: Analyzing
Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 34.1 Describe the anatomy, physiology, and functions of the nose and sinuses, pharynx, larynx, trachea, lungs, pleura, bronchi and alveoli, and rib cage and intercostal muscles, and identify abnormal findings that may indicate impairment of the respiratory system.
MNL Learning Outcome: 3. Interpret abnormal findings of the respiratory system collected during assessment.
4) The nurse prepares to assess a patient's respiratory system. Which structure should the nurse use to locate the approximate position of the larynx?
1. Clavicle
2. Adam's apple
3. First rib
4. Shoulder joint
Page Ref: 1218
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 34.1 Describe the anatomy, physiology, and functions of the nose and sinuses, pharynx, larynx, trachea, lungs, pleura, bronchi and alveoli, and rib cage and intercostal muscles, and identify abnormal findings that may indicate impairment of the respiratory system.
MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the respiratory system.
5) During an assessment, a patient begins to cough. What should the nurse realize about this finding?
1. The patient has a cold.
2. The patient is nervous.
3. Something other than air was entering the larynx.
4. Something other than air was entering the epiglottis.
Page Ref: 1218
Cognitive Level: Analyzing
Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 34.1 Describe the anatomy, physiology, and functions of the nose and sinuses, pharynx, larynx, trachea, lungs, pleura, bronchi and alveoli, and rib cage and intercostal muscles, and identify abnormal findings that may indicate impairment of the respiratory system.
MNL Learning Outcome: 2. Recognize normal findings of the respiratory system collected during assessment and health promotion activities to support the health of this body system.
6) A patient's blood oxygen saturation level is 99% on room air. Which structure should the nurse identify that transports oxygenated blood to the heart?
1. Pulmonary arteries
2. Pulmonary veins
3. Bronchial arteries
4. Bronchial veins
Page Ref: 1219
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 34.1 Describe the anatomy, physiology, and functions of the nose and sinuses, pharynx, larynx, trachea, lungs, pleura, bronchi and alveoli, and rib cage and intercostal muscles, and identify abnormal findings that may indicate impairment of the respiratory system.
MNL Learning Outcome: 2. Recognize normal findings of the respiratory system collected during assessment and health promotion activities to support the health of this body system.
7) A patient is demonstrating poor exhalation. Which health problem is this patient at risk for developing?
1. Pleurisy
2. Pulmonary edema
3. Increased carbon dioxide levels
4. Reduced oxygen capacity of red blood cells
Page Ref: 1223
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 34.1 Describe the anatomy, physiology, and functions of the nose and sinuses, pharynx, larynx, trachea, lungs, pleura, bronchi and alveoli, and rib cage and intercostal muscles, and identify abnormal findings that may indicate impairment of the respiratory system.
MNL Learning Outcome: 3. Interpret abnormal findings of the respiratory system collected during assessment.
8) During the assessment of a patient's respiratory status, the nurse locates the manubrium and the body of the sternum. Which anatomical structure is the nurse assessing?
1. Adam's apple
2. Angle of Louis
3. Intercostal space
4. Xiphoid process
Page Ref: 1220
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 34.1 Describe the anatomy, physiology, and functions of the nose and sinuses, pharynx, larynx, trachea, lungs, pleura, bronchi and alveoli, and rib cage and intercostal muscles, and identify abnormal findings that may indicate impairment of the respiratory system.
MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the respiratory system.
9) During pulmonary function tests, a patient is found to have approximately 500 mL of air moving in and out of the lungs during normal quiet breathing. What should the finding be considered?
1. Tidal volume
2. Expiratory reserve volume
3. Residual volume
4. Vital capacity
Page Ref: 1220
Cognitive Level: Analyzing
Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 34.1 Describe the anatomy, physiology, and functions of the nose and sinuses, pharynx, larynx, trachea, lungs, pleura, bronchi and alveoli, and rib cage and intercostal muscles, and identify abnormal findings that may indicate impairment of the respiratory system.
MNL Learning Outcome: 2. Recognize normal findings of the respiratory system collected during assessment and health promotion activities to support the health of this body system.
10) During the assessment of a patient's respiratory status, the nurse observes the expiration phase as being almost twice as long as the inspiration phase. What is this finding associated with?
1. Chronic lung disease
2. Heart failure
3. Respiratory distress
4. Normal respiration
Page Ref: 1221
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 34.1 Describe the anatomy, physiology, and functions of the nose and sinuses, pharynx, larynx, trachea, lungs, pleura, bronchi and alveoli, and rib cage and intercostal muscles, and identify abnormal findings that may indicate impairment of the respiratory system.
MNL Learning Outcome: 2. Recognize normal findings of the respiratory system collected during assessment and health promotion activities to support the health of this body system.
11) The nurse counts a patient's respirations at 30 per minute. From this finding, what about the patient's respiratory status should cause the nurse concern?
1. Pneumonia is developing.
2. Increased carbon dioxide in the blood is being expelled.
3. Respiratory arrest is beginning.
4. Pain is affecting the respiratory rate.
Page Ref: 1221
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 34.1 Describe the anatomy, physiology, and functions of the nose and sinuses, pharynx, larynx, trachea, lungs, pleura, bronchi and alveoli, and rib cage and intercostal muscles, and identify abnormal findings that may indicate impairment of the respiratory system.
MNL Learning Outcome: 3. Interpret abnormal findings of the respiratory system collected during assessment.
12) A patient is diagnosed with a low iron count. For which potential health problem should the nurse assess this patient?
1. Increased carbon dioxide in the blood
2. Nausea
3. Anxiety
4. Poor tissue oxygenation
Page Ref: 1222
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 34.1 Describe the anatomy, physiology, and functions of the nose and sinuses, pharynx, larynx, trachea, lungs, pleura, bronchi and alveoli, and rib cage and intercostal muscles, and identify abnormal findings that may indicate impairment of the respiratory system.
MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the respiratory system.
13) During the assessment of a patient's nasal cavities, the nurse notes watery nasal discharge and pale turbinates. These findings are consistent with what health problem?
1. Allergies
2. Infection
3. Cocaine use
4. Sinus infection
Page Ref: 1224
Cognitive Level: Analyzing
Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 34.2 Outline the components of the assessment of the respiratory system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.
MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the respiratory system.
14) During a nap, the nurse notes that a patient's respirations periodically stop. How should the nurse document this finding?
1. Tachypnea
2. Bradypnea
3. Apnea
4. Atelectasis
Page Ref: 1224
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment/Communication and Documentation
Learning Outcome: 34.2 Outline the components of the assessment of the respiratory system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.
MNL Learning Outcome: 3. Interpret abnormal findings of the respiratory system collected during assessment.
15) During the palpation of a patient's chest for expansion, the nurse notices a decrease in expansion of the right side. With what health problem is this finding associated? Select all that apply.
1. Emphysema
2. Pneumonia
3. Pleural effusion
4. Heart failure
5. Pneumothorax
Page Ref: 1225
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 34.2 Outline the components of the assessment of the respiratory system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.
MNL Learning Outcome: 3. Interpret abnormal findings of the respiratory system collected during assessment.
16) The nurse percusses hyperresonance over a patient's lungs. With which health problem is this finding associated?
1. Pneumonia
2. Atelectasis
3. Chronic asthma
4. Pleural effusion
Page Ref: 1225
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 34.2 Outline the components of the assessment of the respiratory system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.
MNL Learning Outcome: 3. Interpret abnormal findings of the respiratory system collected during assessment.
17) The nurse is auscultating a patient's lungs. Which breath sound should the nurse identify as abnormal? Select all that apply.
1. Crackles
2. Vesicular
3. Bronchovesicular
4. Wheezes
5. Bronchial
Page Ref: 1226
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 34.2 Outline the components of the assessment of the respiratory system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.
MNL Learning Outcome: 3. Interpret abnormal findings of the respiratory system collected during assessment.
18) A patient is having pulmonary function tests. What should the nurse instruct the patient about the process?
1. "Expect to be sedated for the test."
2. "Anti-nausea medication will be provided prior to the test."
3. "A nose clip will be worn during the test."
4. "Oxygen will be used for a while after the test."
Page Ref: 1220
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning
Learning Outcome: 34.1 Describe the anatomy, physiology, and functions of the nose and sinuses, pharynx, larynx, trachea, lungs, pleura, bronchi and alveoli, and rib cage and intercostal muscles, and identify abnormal findings that may indicate impairment of the respiratory system.
MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the respiratory system.
19) The nurse is caring for an older patient. Which age-related change increases this patient's risk for residual air volume in the lungs?
1. Elasticity of lungs decreases with age.
2. Older adults have a more rapid respiratory rate.
3. There is a tightening of the diaphragm with age.
4. Intercostal muscles become weaker with age.
Page Ref: 1229
Cognitive Level: Analyzing
Client Need & Sub: Health Promotion and Maintenance: Aging Process
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 34.3 Differentiate considerations for assessing the respiratory system of older adults, veterans, individuals in the LGBTQI population, and adults with sequelae of childhood/congenital conditions.
MNL Learning Outcome: 2. Recognize normal findings of the respiratory system collected during assessment and health promotion activities to support the health of this body system.
20) The nurse administers oxygen to a patient who has lost a moderate amount of blood following a motor vehicle crash. What is the primary reason for this intervention?
1. Ease the work of breathing for the patient
2. Compensate for the reduction in circulating oxygen
3. Provide comfort during assessment
4. Prevent shock from developing
Page Ref: 1222
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 34.1 Describe the anatomy, physiology, and functions of the nose and sinuses, pharynx, larynx, trachea, lungs, pleura, bronchi and alveoli, and rib cage and intercostal muscles, and identify abnormal findings that may indicate impairment of the respiratory system.
MNL Learning Outcome: 3. Interpret abnormal findings of the respiratory system collected during assessment.
21) A patient admitted with probable emphysema is scheduled for diagnostic tests. What test should the nurse expect to be prescribed to assess the patient's acid‒base balance?
1. Bronchoscopy
2. Sputum studies
3. Pulse oximetry
4. Arterial blood gases (ABGs)
Page Ref: 1227
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 34.2 Outline the components of the assessment of the respiratory system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.
MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the respiratory system.
22) While preparing a patient for a bronchoscopy, the nurse ensures the suction equipment is available. Why is the nurse taking this precaution?
1. There is a high risk of a reaction to medications used for sedation.
2. Laryngospasm and respiratory distress could follow this test.
3. Suction equipment should always be available.
4. Pulmonary embolus is a complication following this test.
Page Ref: 1227
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Quality & Safety; Practice-Know-How; Use technologies that contribute to safety | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 34.2 Outline the components of the assessment of the respiratory system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.
MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the respiratory system.
23) A patient suspected of having a lung mass asks why a positron emission tomography (PET) scan was ordered instead of a computed tomography (CT) scan. What is the best response by the nurse?
1. "Your doctor prefers to order PET scans."
2. "Why are you concerned about this test?"
3. "PET scans focus on your particular problem."
4. "You will still need a CT scan also."
Page Ref: 1228
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Communication and Documentation
Learning Outcome: 34.2 Outline the components of the assessment of the respiratory system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.
MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the respiratory system.
24) The nurse is instructing a patient on collecting a sputum sample. What is the best time for the nurse to collect this specimen?
1. After a meal
2. Upon awakening from a nap
3. Before a meal
4. Upon awakening in the morning
Page Ref: 1229
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 34.2 Outline the components of the assessment of the respiratory system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.
MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the respiratory system.
25) The nurse is assessing an older patient's respiratory status. What age-related change can predispose this patient to pneumonia? Select all that apply.
1. Slower respiratory rate
2. Less effective cough
3. Immobility
4. Increased pain response
5. Fixed income
Page Ref: 1229
Cognitive Level: Analyzing
Client Need & Sub: Health Promotion and Maintenance: Aging Process
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 34.3 Differentiate considerations for assessing the respiratory system of older adults, veterans, individuals in the LGBTQI population, and adults with sequelae of childhood/congenital conditions.
MNL Learning Outcome: 2. Recognize normal findings of the respiratory system collected during assessment and health promotion activities to support the health of this body system.
26) The nurse assesses a patient's lung sounds. For which finding should the nurse follow-up?
1. Heard crackles earlier, but now hear nothing
2. Hear wheezing in the right lobes, but clear on the left
3. Coarse crackles that clear with coughing
4. Scattered wheezes bilaterally
Page Ref: 1226
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 34.2 Outline the components of the assessment of the respiratory system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.
MNL Learning Outcome: 3. Interpret abnormal findings of the respiratory system collected during assessment.
27) The nurse notes that a patient is susceptible to chronic pulmonary diseases. What did the nurse assess to make this clinical decision?
1. The patient owned and worked a farm.
2. The patient worked in a hospital.
3. The patient is an air traffic controller.
4. The patient played in a band.
Page Ref: 1224
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 34.2 Outline the components of the assessment of the respiratory system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.
MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the respiratory system.
28) The nurse is planning a class for nursing assistants. What should the nurse include as causing interference with accurate pulse oximeter readings? Select all that apply.
1. External light sources
2. Nail polish
3. Inhalation injuries
4. Arterial pulses
5. Placement on cartilage
Page Ref: 1228
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Planning/Teaching/Learning
Learning Outcome: 34.2 Outline the components of the assessment of the respiratory system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.
MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the respiratory system.
29) The nurse wants to assess the apex of a patient's right lung. In which location should the nurse place the stethoscope to assess this patient?
1. Intercostal space, sixth rib near the sternum
2. Intercostal space, fourth rib near the axillary line
3. Below the scapula
4. Near the right clavicle
Page Ref: 1219
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 34.1 Describe the anatomy, physiology, and functions of the nose and sinuses, pharynx, larynx, trachea, lungs, pleura, bronchi and alveoli, and rib cage and intercostal muscles, and identify abnormal findings that may indicate impairment of the respiratory system.
MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the respiratory system.
30) A patient is recovering from a bronchoscopy. What care should the nurse provide to this patient? Select all that apply.
1. Instruct the patient to avoid eating and drinking until the gag reflex returns.
2. Report dark blood-tinged respiratory secretions to the physician.
3. Notify the physician with any breathing difficulty.
4. Administer pain medications immediately following the procedure.
5. Instruct the patient on use of incentive spirometry to use following the procedure.
Page Ref: 1227
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning
Learning Outcome: 34.2 Outline the components of the assessment of the respiratory system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.
MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the respiratory system.
31) A patient is scheduled to have a magnetic resonance imaging scan (MRI). What information is most important for the nurse to obtain before the procedure?
1. Whether the patient is wearing any metal
2. When the patient last ate or drank
3. Whether the patient is allergic to shellfish
4. Whether the patient has any loose teeth
Page Ref: 1228
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 34.2 Outline the components of the assessment of the respiratory system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.
MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the respiratory system.
32) The nurse is preparing to assess a patient with cystic fibrosis. What should the nurse keep in mind about this patient's health problem? Select all that apply.
1. The patient will have difficulty speaking.
2. The patient will have cardiac dysrhythmias.
3. The patient is prone to respiratory infections.
4. The patient will have altered nutritional status.
5. The patient will have thick respiratory secretions.
Page Ref: 1223
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 34.2 Outline the components of the assessment of the respiratory system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.
MNL Learning Outcome: 3. Interpret abnormal findings of the respiratory system collected during assessment.
33) The nurse notes that a patient's respiratory rate and depth constantly change. What structure should the nurse recall is affecting this patient's respirations? Select all that apply.
1. Pons
2. Aortic bodies
3. Carotid bodies
4. Medulla oblongata
5. Number of alveoli
Page Ref: 1221
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 34.1 Describe the anatomy, physiology, and functions of the nose and sinuses, pharynx, larynx, trachea, lungs, pleura, bronchi and alveoli, and rib cage and intercostal muscles, and identify abnormal findings that may indicate impairment of the respiratory system.
MNL Learning Outcome: 2. Recognize normal findings of the respiratory system collected during assessment and health promotion activities to support the health of this body system.
34) During an assessment, the nurse becomes concerned about a patient's lung compliance. What factor about the patient's respiratory status caused the nurse to have this concern? Select all that apply.
1. Patency of the nares
2. Flexibility of the rib cage
3. Status of a sinus infection
4. Elasticity of the lung tissue
5. Pulse oximeter reading of 97%
Page Ref: 1221
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 34.1 Describe the anatomy, physiology, and functions of the nose and sinuses, pharynx, larynx, trachea, lungs, pleura, bronchi and alveoli, and rib cage and intercostal muscles, and identify abnormal findings that may indicate impairment of the respiratory system.
MNL Learning Outcome: 3. Interpret abnormal findings of the respiratory system collected during assessment.
35) The nurse determines that a patient has bronchovesicular breath sounds. What criteria did the nurse use to make this clinical decision? Select all that apply.
1. Medium pitch
2. Heard between the scapula
3. Heard on each side of the sternum
4. Inspiration lasts longer than expiration
5. Inspiration and expiration equal in duration
Page Ref: 1226
Cognitive Level: Analyzing
Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 34.2 Outline the components of the assessment of the respiratory system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.
MNL Learning Outcome: 2. Recognize normal findings of the respiratory system collected during assessment and health promotion activities to support the health of this body system.
36) During an assessment, the nurse learns that a patient has an alteration in the sense of smell. What should the nurse consider as causes of this alteration? Select all that apply.
1. Rhinoplasty
2. Zinc deficiency
3. Deviated septum
4. Olfactory nerve damage
5. Chronic inflammation of the nose
Page Ref: 1224
Cognitive Level: Analyzing
Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 34.2 Outline the components of the assessment of the respiratory system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.
MNL Learning Outcome: 3. Interpret abnormal findings of the respiratory system collected during assessment.
37) A patient who never smoked wonders why the cancer occurred. What is the nurse's best response?
1. "It could have been caused by a high-sodium diet."
2. "Are you sure you never smoked?"
3. "There may have been a genetic predisposition."
4. "No one will ever know."
Page Ref: 1223
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 34.2 Outline the components of the assessment of the respiratory system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.
MNL Learning Outcome: 3. Interpret abnormal findings of the respiratory system collected during assessment.
38) The nurse is preparing a teaching tool on respiratory health. Which information should the nurse include in this tool? Select all that apply.
1. Stop smoking.
2. Restrict fluid intake.
3. Use good hand hygiene.
4. Use good cough technique.
5. Get recommended vaccinations.
Page Ref: 1230
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning
Learning Outcome: 34.4 Summarize topics that nurses teach to promote healthy tissue integrity across the lifespan.
MNL Learning Outcome: 2. Recognize normal findings of the respiratory system collected during assessment and health promotion activities to support the health of this body system.
39) During a home visit, the nurse observes that several family members are experiencing a respiratory infection. Which should the nurse encourage to improve the home environment? Select all that apply.
1. Remove house plants.
2. Limit the use of aerosols.
3. Have radon level checked.
4. Use a wood-burning stove.
5. Remove dust and pet dander.
Page Ref: 1230
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning
Learning Outcome: 34.4 Summarize topics that nurses teach to promote healthy tissue integrity across the lifespan.
MNL Learning Outcome: 2. Recognize normal findings of the respiratory system collected during assessment and health promotion activities to support the health of this body system.
Document Information
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