When assessing whispered pectoriloquy, the nurse should instruct a client to do which of the following?
A) Softly repeat the words ìone-two-three.
When preparing to assess a client's thoracic cage, the nurse should locate which landmark when determining where to begin the assessment of the ribs and intercostal spaces?
C) Sternal angle
The nurse is assessing a client who has been admitted for the treatment of severe dehydration. What might the nurse expect to hear when auscultating the lungs of a client with this fluid volume deficit?
D) Friction rub
A client has sustained a brain stem injury and is being treated in the intensive care unit.Which of the following would the nurse need to consider when assessing this client's respiratory status?
A) The client will have a loss of involuntary respiratory control.
During the health interview, a client tells the nurse that he ìcan't breathe all that wellî at night when he is lying down and that this significantly disrupts his sleep. The nurse should assess this client further for which of the following health problems?
A) Pneumonia
B) Tuberculosis
C) Bronchitis
D) Heart failure
Heart Failure
A client is diagnosed with pulmonary edema, and the nurse is performing a rapid assessment prior to treatment. The nurse would be most concerned about which of the following assessment findings related to the client's sputum?
B) Pink and frothy
Upon entering the examination room, the nurse observes that the client is leaning forward with his arms supporting his body weight. The nurse would recognize this as a tripod position and suspect the presence of which of the following medical problems?
B) Chronic obstructive pulmonary disease
The nurse assesses chest expansion in a 30-year-old man and finds it to be 8 cm. The nurse should document this as which of the following?
D) Normal expansion
A client has a history of emphysema. During the respiratory assessment, the nurse percusses the client's chest, expecting to find which of the following?
B) Hyperresonance
While auscultating a client's lungs, the nurse notes the presence of adventitious sounds.Which of the following actions should the nurse do first?
A) Have the client cough, then listen again
The nurse is preparing to auscultate the client's thorax. Which of the following actions is the priority during this component of assessment?
B) Listen at each site for at least one complete respiratory cycle.
An adult client has been diagnosed with bronchitis. Which of the following would the nurse most likely hear on auscultation?
D) Sonorous wheezes
The nurse is performing a respiratory assessment of a client who is palliative due to severe, uncompensated heart failure. What type of respiratory pattern should the nurse anticipate?
C) Cheyne-Stokes
The school nurse assesses unequal shoulder and scapula height in an adolescent. Which of the following should the nurse assess next?
B) Spinal column
While auscultating a client's trachea, the nurse hears a high, harsh sound with short inspiration and long expiration. The nurse would document which of the following?
D) Bronchial breath sounds
When percussing the scapula of a client, which of the following would the nurse expect to hear?
C) Flatness
A group of students is reviewing the vertical reference lines of the thorax. They demonstrate understanding when they identify which line as a reference line for the posterior thorax?
A) Vertebral line
The nurse is assessing the apices of the client's lungs. The nurse should locate them at which position?
C) Slightly above the clavicle
The nurse is assessing the various lobes of the client's lungs. To gather accurate data, the nurse must assess which lobe anteriorly?
C) Right middle lobe
A nursing instructor is discussing cultural variations in the size of the thorax and impact on lung capacity. Which group would the instructor identify as typically having a larger thorax?
C) Caucasians
The nurse is preparing to perform a focused respiratory assessment on a client. The nurse should be cognizant of what anatomical characteristic of the lungs?
D) The right lung has three lobes, while the left lung has two lobes.
The nurse is conducting the health interview of an adult client who has sought care because of a ìwicked coughî leading to dyspnea. When trying to differentiate between pathologic lung changes and an infection as the etiology of the client's cough and resultant dyspnea, what interview question should the nurse ask?
B) ìHow long have you been experiencing your cough?
During a health screening event, the nurse is assessing a client's risk factors for lung cancer. When addressing the most significant risk factor for lung cancer, the nurse should question the client about which of the following?
A) History of tobacco use
The nurse is assessing a 69-year-old woman's risks for lung disease. The woman states,ìIt shouldn't be a problem for me. My husband smokes quite heavily but I've been a lifelong nonsmoker.î The nurse should recognize the need to teach the client about what topic?
C) Health risks of secondhand smoke
The nurse is assessing a 79-year-old client's posterior thorax during a focused respiratory assessment. The nurse should attribute what assessment finding to age related changes?
B) Slight kyphosis
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) ìPlease say the number 'ninety-nine' for me.î
The nurse is assessing a client's respiratory rate and rhythm during the beginning of a shift. The nurse knows that a normal breathing rate is between approximately 10 and 20 breaths per minute, but the client's rate is 29 breaths per minute. How should the nurse respond to this assessment finding?
B) Ask the client if she has recently exerted herself.
A nurse is caring for a patient whose diagnosis of cystic fibrosis results in the production of large amounts of sticky mucus. The client has a history of repeated hospital admissions for complications of his disease and receives daily treatments to mobilize the secretions. When planning the care of this client, what nursing diagnosis is most plausible?
A) Ineffective Airway Clearance related to respiratory secretions
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 pathophysiological process?
C) Air passing through constricted passageways
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?
D) Place the diaphragm on the client's posterior chest wall.
