N4 test Assessment of the Respiratory System

Ignatavicius & Workman: Medical-Surgical Nursing: Critical Thinking for Collaborative Care, 4th Edition Chapter 27: Assessment of the Respiratory System

1. Which respiratory airways are most prone to collapse?
A. Trachea
B. Mainstem bronchi
C. Lobar bronchi
D. Terminal bronchioles

2. The client’s respiratory pattern is a 1.5-second inhalation followed by a 7-second exhalation. What is your interpretation of this finding? The client:
A. has a normal respiratory pattern.
B. is experiencing some obstruction of airflow.
C. has been engaging in strenuous exercise.
D. has inadequate pulmonary blood flow.

3. The 72-year-old client, who does not appear to have any difficulty breathing, has an arterial blood gas value for the partial pressure of oxygen (PaO2) of 82.5 mm Hg. What is your best action?
A. Administer oxygen.
B. Raise the head of the bed.
C. Notify the physician.
D. Document the finding as the only action.

4. The 55-year-old client tells you that she has smoked two packs of cigarettes per day since she was 14 years old. How many pack-years should you record in the client’s history?
A. 41
B. 55
C. 82
D. 110

5. During pulmonary assessment, you observe the client to have a diaphragmatic excursion of 4 cm. What is your best action?
A. Document the observation as the only action.
B. Keep the client in an upright position.
C. Administer oxygen.
D. Notify the physician.

6. When percussing the area over the right lower lobe, you obtain a dull, thud-like response. What is your best action?
A. Auscultate for breath sounds in this area.
B. Raise the head of the bed.
C. Administer oxygen.
D. Document the findings as the only action.

7. The client has an arterial blood gas pH of 7.48. What is your interpretation? The client:
A. has no problem with hydrogen ion concentration.
B. has an increase in extracellular fluid hydrogen ion concentration (acidosis).
C. has a decrease in extracellular fluid hydrogen ion concentration (alkalosis).
D. is overhydrated.

8. The client is scheduled for pulmonary function tests (PFT). Which instruction should you give to the client the day before the tests?
A. “Do not exercise within 24 hours of testing.”
B. “Do not smoke for 6 to 8 hours before testing.”
C. “Do not eat or drink within 4 hours of testing.”
D. “Do not take aspirin within 24 hours of testing.”

9. The client has had a percutaneous lung biopsy two hours ago. Which clinical manifestations should you report immediately to the physician?
A. Pink-tinged sputum
B. Bruising at the puncture site
C. Enlarged cervical lymph node
D. Lateral displacement of the trachea