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Fundamentals of Nursing Practice (NURS 111 )
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NURSINGTB
Chapter 11: Lungs and Respiratory System
Wilson: Health Assessment for Nursing Practice, 6th Edition
MULTIPLE CHOICE
1. A patient tells the nurse that she has smoked 2 packs of cigarettes a day for 20 years. The
nurse records this as how many pack-years?
a. 10
b. 20
c. 40
d. 60
ANS: C
Two packs of cigarettes 20 years = 40 pack-years. This incorrect calculation was made by
dividing 20 years by 2 packs. Option B is correct if the patient smoked 1 pack per day for 20
years. Option D is correct if the patient smoked 3 packs per day for 20 years or 2 packs a day
for 30 years.
DIF: Cognitive Level: Apply REF: p. 186 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments
2. After taking a brief health history, a nurse needs to complete a focused assessment on which
patient?
a. A male who works as a painter
b. A male who plays basketball and hockey
c. A female who recently moved into a college dormitory
d. A female who has a history of gout
ANS: A
The fumes and chemicals from the paint may expose the patient to respiratory irritants. A
baseline pulmonary assessment needs to be documented. Other patients are not at risk for
pulmonary disease.
DIF: Cognitive Level: Apply REF: p. 186 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Health Screening
3. During a symptom analysis, a patient describes his productive cough and states his sputum is
thick and yellow. Based on these data, the nurse suspects which factor as the cause of these
symptoms?
a. Virus
b. Allergy
c. Fungus
d. Bacteria
ANS: D
NURSINGTB
Bacteria usually produce sputum that is yellow or green in color. A virus usually produces a
nonproductive cough. An allergy usually produces clear sputum. A fungus usually produces
few symptoms. The sputum used to diagnose the fungus is obtained from tracheal aspiration
rather than the patient coughing up the sputum.
DIF: Cognitive Level: Apply | Cognitive Level: Analyze REF: p. 187 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body Systems
4. During the problem-based history, a patient reports coughing up sputum when lying on the
right side, but not when lying on the back or left side. The nurse suspects this patient may
have a lung abscess. What additional question does the nurse ask to gather more data?
a. “Does the sputum have an odor?”
b. “Do you have chest pain when you take a deep breath?”
c. “Have you also experienced tightness in your chest?”
d. “Have you coughed up any blood?”
ANS: A
Sputum with odor and sputum production with change of position is associated with lung
abscess or bronchiectasis. Chest pain on deep breathing is associated with pleural lining
irritation. Tightness in the chest is associated with asthma. Coughing up rust-colored sputum
is associated with pneumonia, but coughing up blood may be associated with lung cancer.
DIF: Cognitive Level: Apply REF: p. 187 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body Systems
5. Which question will give the nurse additional information about the nature of a patient’s
dyspnea?
a. “How often do you see the physician?”
b. “How has this condition affected your day-to-day activities?”
c. “Do you have a cough that occurs with the dyspnea?”
d. “Does your heart rate increase when you are short of breath?”
ANS: B
Question B provides data about the severity of the dyspnea and what actions the patient has
taken to cope with the dyspnea on a daily basis. Question A does not relate specifically to the
patient’s dyspnea. This closed question (Question C) provides data, but does not give
additional facts about the patient’s dyspnea. A closed question limits the amount of
information gathered about the patient’s dyspnea. Question D is a closed-ended question that
does not collect additional data about this episode of dyspnea.
DIF: Cognitive Level: Apply REF: p. 188 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body Systems
6. A patient complains of shortness of breath and having to sleep on three pillows to breathe
comfortably at night. During the nurse’s examination, what findings will suggest that the
cause of this patient’s dyspnea is due to heart disease rather than respiratory disease?
NURSINGTB
DIF: Cognitive Level: Apply REF: p. 200 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body Systems
9. A nurse inspects a patient’s hands and notices clubbing of the fingers. The nurse correlates
this finding with what condition?
a. Pulmonary infection
b. Trauma to the thorax
c. Chronic hypoxemia
d. Allergic reaction
ANS: C
Clubbing develops due to chronic hypoxemia, which occurs in chronic obstructive pulmonary
disease. Pulmonary infection is acute and not associated with chronic hypoxia. Trauma to the
thorax is acute and not associated with chronic hypoxia. Allergic reaction is acute and not
associated with chronic hypoxia.
DIF: Cognitive Level: Apply REF: p. 191 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body Systems
10. A nurse is assessing a patient who was diagnosed with emphysema and chronic bronchitis 5
years ago. During the assessment of this patient’s integumentary system, what finding should
the nurse correlate to this respiratory disease?
a. Dry, flaky skin
b. Clubbing of the fingers
c. Hypertrophy of the nails
d. Hair loss from the scalp
ANS: B
Clubbing of the fingers develops due to chronic hypoxemia, which occurs in chronic
obstructive pulmonary disease. Dry, flaky skin occurs with dehydration. Hypertrophy of the
nails occurs with repeated trauma. Hair loss from the scalp is alopecia, which occurs with
many systemic diseases, but not chronic pulmonary disease.
DIF: Cognitive Level: Apply REF: p. 191 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body Systems
11. A nurse is auscultating the lungs of a healthy male patient and hears crackles on inspiration.
What action can the nurse take to ensure this is an accurate finding?
a. Make sure the bell of the stethoscope is used, rather than the diaphragm.
b. Hold stethoscope firmly to prevent movement when placed over chest hair.
c. Ask the patient not to talk while the nurse is listening to the lungs.
d. Change the patient’s position to ensure accurate sounds.
ANS: B
NURSINGTB
The stethoscope moving even slightly on chest hair can mimic the sound of crackles. Using
the bell will provide inaccurate sounds, but not mimic crackles. When the patient talks during
auscultation, it does interfere with data collection, but the sound is a muffled voice. Changing
the position will not affect the outcome of the assessment if the initial problem remains.
DIF: Cognitive Level: Apply REF: p. 194 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment
12. A patient is admitted to the emergency department with a tracheal obstruction. What sound
does the nurse expect to hear as this patient breathes?
a. Dull sounds on percussion
b. Soft, muffled rhonchi heard over the trachea
c. Bubbling or rasping sounds heard over the trachea
d. High-pitched sounds on inspiration and exhalation
ANS: D
High-pitched sounds on inspiration and exhalation are consistent with stridor. Dull sounds on
percussion occur with pneumonia, pleural effusion, or atelectasis. Soft, muffled rhonchi heard
over the trachea is not a description of stridor. Bubbling or rasping sounds heard over the
trachea is not a description of stridor.
DIF: Cognitive Level: Understand REF: p. 194 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body Systems
13. A nurse auscultates low-pitched, coarse snoring sounds in a patient’s lungs during inhalation.
What is the most appropriate action for the nurse to take at this time?
a. Palpate the posterior thorax for vocal fremitus.
b. Ask the patient to cough and repeat auscultation.
c. Auscultate the posterior thorax for vocal sounds.
d. Percuss the posterior thorax for tone.
ANS: B
The sounds indicate rhonchi, or secretions in the bronchi. The first action to take is to
determine if the rhonchi clear with coughing. If the rhonchi clear, there is no need to further
investigate this finding. An abnormal vocal fremitus (decreased or increased vibrations) is not
expected for this patient. Abnormal vocal sounds (clear and loud sounds) are not expected for
this patient. An abnormal percussion tone (hyperresonance or dull) is not expected for this
patient.
DIF: Cognitive Level: Apply REF: p. 194 | p. 202 | p. 203 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body Systems
14. A nurse had previously heard crackles over both lungs of a patient. As the patient improves,
what lung sounds does the nurse expect to hear in the patient’s lungs?
a. Vesicular breath sounds heard in peripheral lung fields
b. Bronchial breath sounds heard over the bronchi
NURSINGTB
DIF: Cognitive Level: Apply REF: p. 194 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body Systems
17. Where does a nurse expect to hear bronchovesicular lung sounds in a healthy adult?
a. In the lower lobes
b. Over the trachea
c. In the apices of the lungs
d. Near the sternal border
ANS: D
Bronchovesicular breath sounds are normally heard over the central area of the anterior thorax
around the sternal border. Vesicular breath sounds are normally heard in the lower lobes.
Bronchial sounds are normally heard over the trachea. Vesicular breath sounds are normally
heard in the apices of the lungs.
DIF: Cognitive Level: Remember REF: p. 193 | p. 194 | p. 197 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Health Screening
18. A nurse in the emergency department is assessing a patient with a moderate left
pneumothorax. What does this nurse expect to find during the respiratory examination?
a. Increased fremitus over the left chest
b. Tracheal deviation to the left side
c. Hyporesonant percussion tones over the left chest
d. Distant to absent breath sounds over the left chest
ANS: D
The air separating the lung from the chest where the nurse is auscultating creates distant to
absent breath sounds. Increased fremitus occurs over lung consolidation as in lobar
pneumonia or tumor. If this patient had a tension pneumothorax, the trachea would deviate to
the right. Hyperresonant percussion tones are heard when the lung is overinflated as in
emphysema.
DIF: Cognitive Level: Apply REF: p. 203 | p. 204 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body Systems
19. A nurse suspects a patient has a chest wall injury and wants to collect more data about
thoracic expansion. Which is the appropriate technique to use?
a. Place the palmar side of each hand against the lateral thorax at the level of the
waist, ask the patient to take a deep breath, and observe lateral movement of the
hands.
b. Place both thumbs on either side of the patient’s T9 to T10 spinal processes,
extend fingers laterally, ask the patient to take a deep breath, and observe lateral
movement of the thumbs.
c. Place both thumbs on either side of the patient’s T7 to T8 spinal processes, extend
fingers laterally, ask the patient to exhale deeply, and observe lateral inward
movement of the thumbs.
NURSINGTB
d. Place the palmar side of each hand on the shoulders of the patient, ask the patient
to sit up straight and take a deep breath, and observe symmetric movement of the
shoulders.
ANS: B
Option B is the correct technique to assess thoracic expansion. The palms of the hands are not
used and hands are not placed on the lateral thorax. The thoracic level is too high and the
patient does not exhale. The hands are not placed on the shoulders.
DIF: Cognitive Level: Understand REF: p. 198 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment
20. A patient has right lower lobe pneumonia, creating a consolidation in that lung. In assessing
for vocal fremitus, the nurse found increased fremitus over the right lower lung. What finding
does the nurse anticipate when assessing vocal resonance to confirm the consolidation?
a. Bronchophony reveals the patient’s spoken “99” as clear and loud.
b. No sounds are expected since sounds cannot be transmitted through consolidation.
c. Egophony reveals indistinguishable sounds when the patient says “e-e-e.”
d. Whispered pectoriloquy reveals a muffled sound when the patient says “1-2-3.”
ANS: A
Option A is an abnormal finding and occurs in consolidation. The abnormal finding is hearing
a clear sound. Options C and D are normal findings.
DIF: Cognitive Level: Analyze REF: p. 200 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body Systems
21. A nurse is assessing for vocal (tactile) fremitus on a patient with pulmonary edema. Which is
the appropriate technique to use?
a. Systematically percuss the posterior chest wall following the same pattern that is
used for auscultation and listen for a change in tone from resonant to dull.
b. Place the pads of the fingers on the right and left thoraces and palpate the texture
and consistency of the skin feeling for a crackly sensation under the fingers.
c. Place the palms of the hands on the right and left thoraces, ask the patient to say
“99,” and feel for vibrations.
d. Place both thumbs on either side of the patient’s spinal processes, extend fingers
laterally, ask the patient to take a deep breath, and feel for vibrations.
ANS: C
Option C is the correct technique for vocal fremitus. Option A is the technique for percussing
the thorax for tones. Option B is the technique for detecting crepitus. Option D is not the
correct technique.
DIF: Cognitive Level: Understand REF: p. 199 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment
NURSINGTB
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body Systems
25. Which patient should the nurse assess first?
a. The patient whose respiratory rate is 26 breaths/min and whose trachea deviates to
the right.
b. The patient who has pleuritic chest pain, bilateral crackles, a productive cough of
yellow sputum, and fever.
c. The patient who is short of breath, using pursed-lip breathing, and in a tripod
position.
d. The patient whose respiratory rate is 20 breaths/min, and has eight-word dyspnea
and expiratory wheezes.
ANS: A
Option A is a description of a left tension pneumothorax. The key manifestation is deviation
of the trachea from midline, which indicates high intrathoracic pressure from the left that is
pushing the mediastinum out of alignment. The respiratory rate indicates tachypnea. Option B
is a description of a patient with pneumonia who needs to be examined, but this is not a
life-threatening condition. Option C is a description of a patient with emphysema, a chronic
disease. This patient may have these manifestations frequently and does not need to be
examined immediately. Option D is a description of a patient who is having an asthma attack,
but it is not a life-threatening attack; the respiratory rate is the upper limits of normal; the
dyspnea is abnormal, but not far from normal; and the wheezing is on expiration only.
DIF: Cognitive Level: Analyze REF: p. 203 | p. 204 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body Systems
26. A patient reports a productive cough with yellow sputum, fever, and a sharp pain when taking
a deep breath to cough. Based on these data, what abnormal finding will the nurse anticipate
on examination?
a. Decreased breath sounds on auscultation
b. Increased tactile fremitus and dull percussion tones
c. Inspiratory wheezing found on auscultation
d. Muffled sounds heard when the patient says “e-e-e”
ANS: B
The data describe purulent sputum and inflammation of the pleura that may occur in
pneumonia. Additional findings include increased tactile fremitus and dull percussion tones,
indicating congested or consolidated lung tissues. Decreased breath sounds on auscultation are
consistent with emphysema or atelectasis when alveoli are narrowed or destroyed. Inspiratory
wheezing found on auscultation is consistent with narrowing of bronchi that may occur in
asthma. Muffled sounds heard when the patient says “e-e-e” is a normal finding on vocal
resonance (bronchophony or egophony).
DIF: Cognitive Level: Apply REF: p. 200 | p. 202 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body Systems
NURSINGTB
27. A nurse palpating the chest of a patient finds increased fremitus bilaterally. What is the
significance of this finding?
a. An expected finding
b. Chronic obstructive pulmonary disease
c. Bilateral pneumonia
d. Bilateral pneumothorax
ANS: C
Increased fremitus occurs when lung tissues are congested or consolidated, which may occur
in patients who have pneumonia or a tumor. An increase in fremitus from normal is not an
expected finding. Air trapping in chronic obstructive pulmonary disease causes a decreased
fremitus. Air in the pleural space causes a decreased fremitus.
DIF: Cognitive Level: Apply REF: p. 202 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body Systems
MULTIPLE RESPONSE
1. What are the functions of the upper airways? (Select all that apply.)
a. Conduct air to lower airway.
b. Provide area for gas exchange.
c. Prevent foreign matter from entering respiratory system.
d. Warm, humidify, and filter air entering lungs.
e. Provide transportation of oxygen and carbon dioxide between alveoli and cells.
ANS: A, C, D
Options A, C, and D are functions of the upper airway. Gas exchange occurs in the alveoli.
The cardiovascular system provides transportation of oxygen and carbon dioxide between
alveoli and cells.
DIF: Cognitive Level: Remember REF: p. 183 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments
2. On inspection, the nurse finds the patient’s anteroposterior diameter of the chest to be the
same as the lateral diameter. What other findings does this nurse expect during the
examination? (Select all that apply.)
a. Inspiratory wheezing found on auscultation
b. Hyperresonance heard on percussion
c. Decreased breath sounds heard on auscultation
d. Deceased diaphragmatic excursion on percussion
e. A sharp, abrupt pain reported when the patient breathes deeply
f. Decreased to absent vibration on vocal fremitus
ANS: B, C, D, F
NURSINGTB
Options A, D, E, and F are expected findings from a lung and respiratory assessment of a
healthy adult. A respiratory rate of 24 breaths/min is considered tachypnea. Bronchophony
revealing clear voice sounds is not performed unless there is an indication of consolidation of
the lung, or if there was an abnormal finding of tactile fremitus. The expected finding is
muffled voiced sounds rather than clear.
DIF: Cognitive Level: Apply REF: p. 201 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments
COMPLETION
1. A patient tells the nurse that he has smoked packs of cigarettes a day for 14 years. The
number of packs the nurse should record in the medical record is ___ pack-years.
ANS:
21
packs of cigarettes 14 years = 21 pack-years.
DIF: Cognitive Level: Apply REF: p. 186 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments
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11 - text
Course: Fundamentals of Nursing Practice (NURS 111 )
40 Documents
Students shared 40 documents in this course
University: Pierce College
Was this document helpful?
NURSINGTB.COM
Chapter 11: Lungs and Respiratory System
Wilson: Health Assessment for Nursing Practice, 6th Edition
MULTIPLE CHOICE
1. A patient tells the nurse that she has smoked 2 packs of cigarettes a day for 20 years. The
nurse records this as how many pack-years?
a.
10
b.
20
c.
40
d.
60
ANS: C
Two packs of cigarettes 20 years = 40 pack-years. This incorrect calculation was made by
dividing 20 years by 2 packs. Option B is correct if the patient smoked 1 pack per day for 20
years. Option D is correct if the patient smoked 3 packs per day for 20 years or 2 packs a day
for 30 years.
DIF: Cognitive Level: Apply REF: p. 186
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments
2. After taking a brief health history, a nurse needs to complete a focused assessment on which
patient?
a.
A male who works as a painter
b.
A male who plays basketball and hockey
c.
A female who recently moved into a college dormitory
d.
A female who has a history of gout
ANS: A
The fumes and chemicals from the paint may expose the patient to respiratory irritants. A
baseline pulmonary assessment needs to be documented. Other patients are not at risk for
pulmonary disease.
DIF: Cognitive Level: Apply REF: p. 186
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Health Screening
3. During a symptom analysis, a patient describes his productive cough and states his sputum is
thick and yellow. Based on these data, the nurse suspects which factor as the cause of these
symptoms?
a.
Virus
b.
Allergy
c.
Fungus
d.
Bacteria
ANS: D
NURSINGTB.COM
Health Assessment for Nursing Practice 6th Edition Wilson Test Bank
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