Chapter 14: Pulmonary Clinical Assessment and Diagnostic Procedures

 

Complete Chapter Questions With Answers

 

Sample Questions Are Posted Below

 

MULTIPLE CHOICE

 

1. The nurse hears a loud, low-pitched sound when percussing normal lung tissue. The next action should be to:

a.	complete the assessment, noting that resonance, a normal breath sound, was heard.
b.	have the patient cough and repeat the auscultation to determine whether there is an obstruction in the airway.
c.	have the patient use the incentive spirometer hourly times three and reassess the breath sounds.
d.	have the patient cough deeply and repeat the auscultation.

 

ANS:   A

Resonance is a loud, low-pitched sound of long duration and hollow quality.

 

DIF:    Cognitive Level: Application REF:    272

OBJ:    Nursing Process: Assessment TOP:    Pulmonary Clinical Assessment

MSC:   NCLEX: Health Promotion and Maintenance

 

2. The nurse hears high-pitched breath sounds over the trachea. This is an example of:

a.	stridor.
b.	rales.
c.	rhonchi.
d.	normal breath sounds.

 

ANS:   D

High-pitched breath sounds over the trachea are normal breath sounds.

 

DIF:    Cognitive Level: Analysis      REF:    Table 14-2

OBJ:    Nursing Process: Assessment TOP:    Pulmonary Clinical Assessment

MSC:   NCLEX: Health Promotion and Maintenance

 

3. To determine acid-base balance the nurse will evaluate:

a.	FIO2 and PaO2.
b.	serum sodium and potassium levels.
c.	partial pressure of arterial carbon dioxide (PaCO2) and plasma bicarbonate level (HCO3–).
d.	arterial oxygen saturation (SaO2) and oxygen saturation by pulse oximetry (SpO2).

 

ANS:   C

The pH is calculated using PaCO₂ and HCO₃^–.

 

DIF:    Cognitive Level: Comprehension       REF:    275

OBJ:    Nursing Process: Assessment TOP:    Pulmonary Laboratory Studies

MSC:   NCLEX: Physiological Integrity: Reduction of Risk Potential

 

4. The nurse observes that the patient’s ventilations become progressively more shallow until the patient actively and forcefully exhales. This is a sign of:

a.	tidal volume.
b.	positive end-expiratory breathing.
c.	air trapping or obstructed breathing.
d.	pulmonary edema.

 

ANS:   C

Patients with chronic obstructive pulmonary disease often experience obstructive breathing, or air trapping. As the patient breathes, air becomes trapped in the lungs and ventilations become progressively more shallow until the patient actively and forcefully exhales.

 

DIF:    Cognitive Level: Evaluation   REF:    271

OBJ:    Nursing Process: Assessment TOP:    Pulmonary Clinical Assessment

MSC:   NCLEX: Physiological Integrity: Physiological Adaptation

 

5. The nurse observes a tracheal shift to the same side as the pathology, dullness on percussion, and diminished breath sounds. These are signs that the patient has:

a.	pneumonia.
b.	atelectasis.
c.	pulmonary edema.
d.	adult respiratory distress syndrome.

 

ANS:   B

In atelectasis, the trachea shifts to the same side as the problem, and in pneumothorax the trachea shifts to the side opposite the problem.

 

DIF:    Cognitive Level: Analysis      REF:    271

OBJ:    Nursing Process: Assessment TOP:    Pulmonary Clinical Assessment

MSC:   NCLEX: Physiological Integrity: Physiological Adaptation