Chapter 59: Assessment of the Respiratory System Nursing School Test Banks

Black & Hawks: Medical-Surgical Nursing, 8th Edition

Test Bank

Chapter 59: Assessment of the Respiratory System

MULTIPLE CHOICE

1. A client says to the nurse, Its hard for me to breathe; I feel winded all the time. The nurse would record this subjective feeling on the chart as

a.

apnea.

b.

dyspnea.

c.

respiratory fatigue

d.

tachypnea.

ANS: B

Dyspnea is one of the most common manifestations experienced by clients with pulmonary and cardiac disorders. It is a subjective manifestation and reflects the clients assessment of the degree of work of breathing for a given task or effort.

DIF: Comprehension/Understanding REF: p. 1526 OBJ: Intervention

MSC: Physiological Integrity Physiological Adaptation-Pathophysiology

2. A client with pulmonary disease appears more comfortable after respiratory therapy but still feels short of breath. To measure the clients respiratory improvement, the nurse would use a

a.

Candle Scale.

b.

pulmonary function test.

c.

Treadmill test.

d.

Visual Analogue Scale.

ANS: D

The Visual Analogue Scale is used to quantify breathlessness in response to particular questions. It is easy to understand, and the amount of dyspnea during various activities can be assessed. Pulmonary function testing provides information about mechanical respiratory function. A treadmill test would not be used to assess dyspnea. A Candle Scale for dyspnea does not exist.

DIF: Application/Applying REF: pp. 1526-1527

OBJ: Assessment

MSC: Physiological Integrity Reduction of Risk Potential-System Specific Assessments

3. Evaluating the respiratory status of a 59-year-old man with vague complaints of respiratory problems, the nurse would know the assessment that is normal is

a.

an inspiratory wheeze heard only with a stethoscope.

b.

dyspnea with mild exertion.

c.

reports of loud snoring by the clients spouse.

d.

the absence of sputum production after coughing.

ANS: D

The tracheobronchial tree normally produces about 3 ounces of mucus a day as part of the normal cleansing mechanism. However, sputum production with coughing is not normal.

DIF: Comprehension/Understanding REF: pp. 1527-1528

OBJ: Assessment

MSC: Physiological Integrity Reduction of Risk Potential-System Specific Assessments

4. A 44-year-old man with active pulmonary tuberculosis is experiencing hemoptysis, which the nurse understands describes

a.

bloody sputum.

b.

chest pain.

c.

constant cough.

d.

dyspnea.

ANS: A

Hemoptysis is blood expectorated from the mouth in the form of gross blood, frankly bloody sputum, or blood-tinged sputum.

DIF: Comprehension/Understanding REF: p. 1528 OBJ: Assessment

MSC: Physiological Integrity Reduction of Risk Potential-System Specific Assessments

5. The nurse would explain to a client with complaints of wheezing and chest tightness that wheezing occurs when

a.

air is passing through a narrowed airway.

b.

air is trapped in the alveoli.

c.

an allergic reaction is taking place.

d.

sputum production is increased.

ANS: A

Wheezing sounds are produced when air passes through partially obstructed or narrowed airways on inspiration or expiration.

DIF: Comprehension/Understanding REF: p. 1528 OBJ: Intervention

MSC: Physiological Integrity Physiological Adaptation-Pathophysiology

6. An older adult client says, I need to get a shot so that Ill never get pneumonia again. The most helpful response by the nurse would be

a.

Immunization for pneumonia must be repeated every year.

b.

Most older people get flu shots, but they dont protect you from pneumonia.

c.

Pneumovax vaccine can protect you against one type of pneumonia.

d.

You cannot get a shot, or immunization, for pneumonia.

ANS: C

The nurse should ask older adults about immunization against pneumonia (polyvalent pneumococcal vaccine, Pneumovax) and influenza. Ask the client to list the dates of these immunizations. Pneumovax provides lifelong immunity against pneumococcal pneumonia, whereas flu shots must be received annually in the fall.

DIF: Application/Applying REF: p. 1529 OBJ: Intervention

MSC: Health Promotion and Maintenance Prevention and/or Early Detection of Health Problems-Immunizations

7. When a 49-year-old client tells the nurse he has smoked half a pack of unfiltered cigarettes a day since he was 19 years old, the nurse would record the pack-years as

a.

15.

b.

20.

c.

25.

d.

30.

ANS: A

The nurse should inquire about any history of smoking tobacco products, calculating the pack-years, which helps to quantify the smoking history: years of smoking packs smoked per day = pack-years.

DIF: Application/Applying REF: p. 1531 OBJ: Assessment

MSC: Physiological Integrity Reduction of Risk Potential-System Specific Assessments

8. A client has just returned from China and is concerned about possible respiratory disorders. The nurse would advise the client to have a screening to assess for exposure to

a.

adult respiratory distress syndrome (ARDS).

b.

histoplasmosis.

c.

tuberculosis.

d.

Valley fever.

ANS: C

The nurse should ask about recent travel to areas where respiratory diseases are prevalent, such as Asia (tuberculosis), the Ohio River Valley (histoplasmosis), and the San Joaquin Valley (Valley fever). Living in cities with polluted air has also been related to asthma.

DIF: Application/Applying REF: p. 1531 OBJ: Intervention

MSC: Health Promotion and Maintenance Prevention and/or Early Detection of Health Problems-Health Screening

9. A client being treated for emphysema has a chronic productive cough. The nurse would assess a characteristic feature of clients with long-term emphysema, which is

a.

barrel chest.

b.

broken vessels in the nose.

c.

erythematous ear lobes.

d.

pectus excavatum.

ANS: A

Barrel chest occurs when the chest anteroposterior (AP) measurement is increased and equals the transverse measurement. It is a characteristic finding in clients with chronic disorders that interfere with ventilation (e.g., emphysema).

DIF: Application/Applying REF: p. 1533 OBJ: Assessment

MSC: Physiological Integrity Reduction of Risk Potential-System Specific Assessments

10. The nurse preparing to assess a client for the presence of clubbing would instruct the client to

a.

place both hands on a flat surface and splay the fingers.

b.

place the nails of the ring fingers together.

c.

sit upright and lean over the bedside table.

d.

walk 50 feet up the hall as quickly as possible.

ANS: B

Early clubbing may be assessed by using the Schamroth technique. The client places the nails of the fourth (ring) fingers together while extending the other fingers together, then holds the hands up. A diamond-shaped space between the nails is a normal finding; that is, clubbing is absent.

DIF: Application/Applying REF: pp. 1532, 1534

OBJ: Assessment

MSC: Physiological Integrity Reduction of Risk Potential-System Specific Assessments

11. The nurse clinician performing percussion of the chest on a client assesses a low-pitched, hollow sound over the middle lobe. The nurse would record this finding as

a.

dull, and refer the client to an allergist.

b.

hyperresonant, and refer to a physician for work-up.

c.

resonant and document the finding, taking no other action.

d.

tympany, and refer the client to radiology for a chest x-ray.

ANS: C

Resonant sounds are low-pitched, hollow sounds heard over normal lung tissue.

DIF: Application/Applying REF: pp. 1533-1535

OBJ: Assessment

MSC: Physiological Integrity Reduction of Risk Potential-System Specific Assessments

12. When the nurse hears a high, hollow, drum-like sound while percussing the right chest of a young man with a right pneumothorax, the nurse would record this finding as

a.

dullness.

b.

flatness.

c.

resonance.

d.

tympany.

ANS: D

Tympanic notes are high, hollow, drum-like sounds heard with percussion over the stomach, a large tension pneumothorax, or a large air-filled chamber.

DIF: Application/Applying REF: p. 1533 OBJ: Assessment

MSC: Physiological Integrity Reduction of Risk Potential-System Specific Assessments

13. The nurse auscultating the chest of a client with chronic bronchitis would expect to hear the characteristic adventitious breath sound of

a.

bronchovesicular sounds in the bases.

b.

crackles throughout the lung fields.

c.

rhonchi on expiration.

d.

wheezes on inspiration.

ANS: C

Rhonchi (gurgles) result when air passes through fluid-filled narrow passages. Diseases with excess mucus production (e.g., bronchitis) are associated with rhonchi on expiration.

DIF: Comprehension/Understanding REF: pp. 1533-1535

OBJ: Assessment

MSC: Physiological Integrity Reduction of Risk Potential-System Specific Assessments

14. Before drawing blood for an arterial blood gas (ABG), the nurse would perform a/an

a.

Allens test.

b.

incentive spirometer assessment.

c.

Schillings test.

d.

test for peripheral perfusion.

ANS: A

Allens test is a quick assessment of collateral circulation in the hand and is essential for testing collateral circulation before performing a radial artery puncture (e.g., collecting ABG sample).

DIF: Application/Applying REF: p. 1539 OBJ: Assessment

MSC: Physiological Integrity Reduction of Risk Potential-Potential for Complications of Diagnostic Tests/Treatments/Procedures

15. The nurse reviews the results of the arterial carbon dioxide tension (PaCO2) of a client with asthma to obtain information relative to the

a.

contribution of gas exchange.

b.

effectiveness of alveolar ventilation.

c.

evidence of atelectasis.

d.

presence of respiratory alkalosis.

ANS: B

Arterial oxygen tension (PaO2) reflects efficiency of gas exchange, whereas PaCO2 reflects effectiveness of alveolar ventilation.

DIF: Analysis/Analyzing REF: p. 1539 OBJ: Assessment

MSC: Physiological Integrity Reduction of Risk Potential-Laboratory Values

16. The nurse would explain to a client that the most helpful test in the evaluation of a possible pulmonary embolus is

a.

alveolar lavage.

b.

bronchoscopy.

c.

gallium scan.

d.

ventilation-perfusion scan.

ANS: D

Ventilation-perfusion scanning is used to assess lung ventilation and lung perfusion. These scans are valuable in diagnosing pulmonary embolism, pulmonary infarction, emphysema, fibrosis, and bronchiectasis.

DIF: Comprehension/Understanding REF: p. 1537 OBJ: Intervention

MSC: Physiological Integrity Reduction of Risk Potential-Diagnostic Tests

MULTIPLE RESPONSE

1. The nurse preparing a client for a bronchoscopy would include information about its (Select all that apply)

a.

ability to visualize gas exchange at the alveolar level.

b.

limitation of not being able to take tissue biopsies.

c.

therapeutic use to remove retained secretions.

d.

usefulness in diagnosing tumors, inflammation, and strictures.

ANS: C, D

A bronchoscopy can be used for both therapeutic and diagnostic purposes. By directly visualizing the larynx, trachea, and bronchi, it can be used to diagnose tumors, inflammation, and strictures; obtain tissue biopsies; remove retained secretions and foreign bodies; and control bleeding within the bronchus. It cannot be used to visualize gas exchange.

DIF: Comprehension/Understanding REF: p. 1537 OBJ: Intervention

MSC: Physiological Integrity Reduction of Risk Potential-Diagnostic Tests

Elsevier items and derived items 2009 by Saunders, an imprint of Elsevier Inc.

Some material was previously published.

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