Download Chapter 11: Lungs and Respiratory System Test Bank MULTIPLE

Chapter 11: Lungs and Respiratory System
Test Bank
MULTIPLE CHOICE
1. A patient tells the nurse that she has smoked two 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
Feedback
A
B
C
D
This incorrect calculation was made by dividing 20 years by 2 packs.
This is correct if the patient smoked 1 pack per day for 20 years.
Two packs of cigarettes  20 years = 40 pack-years.
This 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: 197, Box 11-1
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
Feedback
A
B
C
D
The fumes and chemicals from the paint may expose the patient to respiratory
irritants. A baseline pulmonary assessment needs to be documented.
This patient is not at risk for pulmonary disease.
This patient is not at risk for pulmonary disease.
This patient is not at risk for pulmonary disease.
DIF: Cognitive Level: Apply
REF: 198
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
Feedback
A
B
C
D
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.
Bacteria usually produce sputum that is yellow or green in color.
DIF: Cognitive Level: Apply
REF: 198
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
Feedback
A
B
C
D
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: 198
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
Feedback
A
B
C
D
This question does not relate specifically to the patient’s dyspnea.
This question provides data about the severity of the dyspnea and what actions
the patient has taken to cope with the dyspnea on a daily basis.
This question provides data, but does not give additional facts about the patient’s
dyspnea.
This is a closed-ended question that does not collect additional data about this
episode of dyspnea.
DIF: Cognitive Level: Apply
REF: 199
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?
a. Increased anteroposterior diameter
b. Clubbing of the fingers
c. Bilateral peripheral edema
d. Increased tactile fremitus
ANS: C
Feedback
A
B
C
D
This is seen with lung hyperinflation and may be associated with emphysema.
This is associated with chronic hypoxia and may be associated with cystic
fibrosis or chronic obstructive pulmonary disease.
This indicates heart failure; dyspnea occurs because the heart cannot adequately
perfuse the lungs.
This occurs when vibrations are enhanced and is associated with consolidation
that may occur in pneumonia or tumor.
DIF: Cognitive Level: Analyze
REF: 199
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body
Systems
7. During a history, a nurse notices a patient is short of breath, is using pursed-lip breathing, and
maintains a tripod position. Based on these data, what abnormal finding should the nurse
expect to find during the examination?
a. Increased tactile fremitus
b. Inspiratory and expiratory wheezing
c. Tracheal deviation
d. An increased anteroposterior diameter
ANS: D
Feedback
A
B
Increased tactile fremitus occurs when vibrations are enhanced and is associated
with consolidation that may occur in pneumonia or tumor.
Inspiratory and expiratory wheezing is associated with asthma.
C
D
Tracheal deviation is associated with tension pneumothorax.
An increased anteroposterior diameter is consistent with emphysema.
DIF: Cognitive Level: Analyze
REF: 199| 207
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body
Systems
8. A nurse notices a patient’s chest wall moving in during inspiration and out during expiration.
What additional assessment must the nurse perform immediately?
a. Palpate for tracheal deviation.
b. Auscultate for bronchovesicular breath sounds in the lung periphery.
c. Palpate posterior thoracic muscles for tenderness.
d. Auscultate for absence of breath sounds in the lung periphery.
ANS: A
Feedback
A
B
C
D
Chest wall moving in during inspiration and out during expiration is paradoxical
chest wall movement. It can be caused by a tension pneumothorax, which
increases intrathoracic pressure in the thorax, causing tracheal deviation and
indicating mediastinal shift.
Tension pneumothorax does not create bronchovesicular breath sounds in the
lung periphery.
This is performed when the patient has air in the subcutaneous tissue or pleural
friction rub.
Absent breath sounds may be found in pneumothorax, but if the patient has a
tension pneumothorax, tracheal deviation is a more important sign.
DIF: Cognitive Level: Apply
REF: 199| 213-214| 220
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
Feedback
A
B
C
D
Pulmonary infection is acute and not associated with chronic hypoxia.
Trauma to the thorax is acute and not associated with chronic hypoxia.
Clubbing develops due to chronic hypoxemia, which occurs in chronic
obstructive pulmonary disease.
Allergic reaction is acute and not associated with chronic hypoxia.
DIF: Cognitive Level: Apply
REF: 202
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
Feedback
A
B
C
D
Dry, flaky skin occurs with dehydration.
Clubbing of the fingers develops due to chronic hypoxemia, which occurs in
chronic obstructive pulmonary disease.
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: 202
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
Feedback
A
B
C
D
Using the bell will provide inaccurate sounds, but not mimic crackles.
The stethoscope moving even slightly on chest hair can mimic the sound of
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: 203-204
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
Feedback
A
B
C
D
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.
High-pitched sounds on inspiration and exhalation are consistent with stridor.
DIF: Cognitive Level: Understand
REF: 206
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
Feedback
A
B
C
D
An abnormal vocal fremitus (decreased or increased vibrations) is not expected
for this patient.
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.
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: 203-204
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
c. Bronchovesicular breath sounds heard over the apices
d. Rhonchi heard over the main bronchi
ANS: A
Feedback
A
B
C
D
Vesicular breath sounds heard in peripheral lung fields are an expected finding
for healthy lungs.
Bronchial breath sounds are heard over the trachea.
Bronchovesicular breath sounds are heard anteriorly near the sternal border first
and second intercostals space.
Rhonchi are adventitious sounds indicating secretions in the bronchi.
DIF: Cognitive Level: Apply
REF: 206
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments
15. The nurse is comparing pitch and duration of the various types of a patient’s breath sounds
and recognizes which one of these as an expected finding?
a. Bronchial sounds are low-pitched and have a 2:1 inspiratory-versus-expiratory
ratio.
b. Bronchovesicular sounds have a moderate pitch and 1:1
expiratory-versus-inspiratory ratio.
c. Vesicular breath sounds are high-pitched and have a 1:2
inspiratory-versus-expiratory ratio.
d. Wheezes are low-pitched and have a 2.5:1 inspiratory-versus-expiratory ratio.
ANS: B
Feedback
A
B
C
D
Bronchial sounds are high pitched with a duration of 1:2
inspiration-to-expiration is the correct statement.
Bronchovesicular sounds having a moderate pitch and 1:1
expiratory-versus-inspiratory ratio is a normal finding.
Vesicular sounds are low pitched with a duration of 2.5:1
inspiration-to-expiration is the correct statement.
Wheezes are high-pitched and have no specific duration because they are
adventitious sounds.
DIF: Cognitive Level: Understand
REF: 205-206
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments
16. On inspection, a nurse finds the patient’s anteroposterior diameter of the chest to be the same
as the lateral diameter. Based on this finding, what additional data does the nurse anticipate?
a. Increased vocal fremitus on palpation
b. Dull tones heard on percussion
c. Decreased breath sounds on auscultation
d. Complaint of sharp chest pain on inspiration
ANS: C
Feedback
A
B
C
D
Increased fremitus occurs when the vibrations feel enhanced. This is found when
lung tissues are congested or consolidated, which may occur in patients who
have pneumonia or a tumor.
Dull tones may be heard in patients with pneumonia, pleural effusion, or
atelectasis.
The equal anteroposterior and lateral diameters of the chest indicate air trapping
from enlarged or destroyed alveoli. This air trapping causes decreased to absent
breath sounds on auscultation.
Complaint of sharp chest pain on inspiration is pleuritic chest pain associated
with pleural lining irritation and may occur in a patient with pleurisy or
pneumonia.
DIF: Cognitive Level: Apply
REF: 206-208| 219
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
Feedback
A
B
C
D
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.
Bronchovesicular breath sounds are normally heard over the central area of the
anterior thorax around the sternal border.
DIF: Cognitive Level: Remember
REF: 205-206
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
Feedback
A
B
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.
C
D
Hyperresonant percussion tones are heard when the lung is overinflated as in
emphysema.
The air separating the lung from the chest where the nurse is auscultating creates
distant to absent breath sounds.
DIF: Cognitive Level: Apply
REF: 206| 220
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.
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
Feedback
A
B
C
D
The palms of the hands are not used and hands are not placed on the lateral
thorax.
This is the correct technique to assess thoracic expansion.
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: 209-210| 214
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
Feedback
A
This is an abnormal finding and occurs in consolidation.
B
C
D
The abnormal finding is hearing a clear sound.
This is a normal finding.
This is a normal finding.
DIF: Cognitive Level: Analyze
REF: 213| 218
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
Feedback
A
B
C
D
This is the technique for percussing the thorax for tones.
This is the technique for detecting crepitus.
This is the correct technique for vocal fremitus.
This is not the correct technique.
DIF: Cognitive Level: Understand
REF: 210| 215
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
22. A nurse examines a patient with a pleural effusion and finds decreased fremitus. What
additional abnormal finding should the nurse anticipate during further examination?
a. An increase in the anteroposterior to lateral ratio
b. Hyperresonance over the affected area
c. Absent breath sounds in the affected area
d. Increased vocal fremitus over the affected area
ANS: C
Feedback
A
B
C
D
An increase in the anteroposterior to lateral ratio occurs in overinflated lungs as
in emphysema.
Hyperresonance over the affected area occurs in overinflated lungs as in
emphysema.
Absent breath sound in the affected area is anticipated because the fluid in the
pleural space prevents breath sounds from being heard.
Increased vocal fremitus over the affected area is associated with consolidation
that occurs with pneumonia or tumor. Fremitus is decreased to absent in pleural
effusion.
DIF: Cognitive Level: Analyze
REF: 206| 210| 215| 218
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body
Systems
23. A patient is suspected of having a lung consolidation. A nurse uses the three techniques for
assessing vocal resonance in this patient. What is the expected finding among the three
procedures that will help eliminate consolidation as a problem?
a. The nurse documents clearly hearing the patient say “99.”
b. The nurse documents hearing muffled sounds when the patient says “1-2-3.”
c. The nurse documents hearing no sounds when the patient says “e-e-e.”
d. The nurse documents clearly hearing the patient say “a-a-a.”
ANS: B
Feedback
A
B
C
D
Clear sounds are heard when a consolidation is present.
Muffled sounds of “1-2-3,” “e-e-e,” or “99” are heard when no consolidation is
found.
Clear sounds are heard when a consolidation is present.
Clear sounds are heard when a consolidation is present.
DIF: Cognitive Level: Analyze
REF: 213
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body
Systems
24. In reviewing the patient’s record, the nurse notes that the patient has air in the subcutaneous
tissue. The nurse validates that this patient has crepitus with which finding?
a. Asymmetric expansion of the chest wall on inhalation
b. Increased transmission of vocal vibrations on auscultation
c. Crackling sensation under the skin of the chest on palpation
d. Coarse grating sounds heard over the mediastinum on inspiration
ANS: C
Feedback
A
B
C
D
Asymmetric chest expansion occurs with rib fracture or chest wall injury.
Increased vocal fremitus occurs with lung consolidation.
A crackling sensation is the finding when crepitus is present.
Coarse grating sounds heard over the mediastinum on inspiration does not
validate crepitus.
DIF: Cognitive Level: Apply
REF: 209
TOP: Nursing Process: Assessment
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 per minute 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 8-word dyspnea and
expiratory wheezes.
ANS: A
Feedback
A
B
C
D
This 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.
This is a description of a patient with pneumonia who needs to be examined, but
this is not a life-threatening condition.
This 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.
This 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: 201| 213-214| 220
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
Feedback
A
B
C
D
Decreased breath sounds on auscultation is consistent with emphysema or
atelectasis when alveoli are narrowed or destroyed.
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.
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: 198-199| 210| 215| 218
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body
Systems
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
Feedback
A
B
C
D
An increase in fremitus from normal is not an expected finding.
Air trapping in chronic obstructive pulmonary disease causes a decreased
fremitus.
Increased fremitus occurs when lung tissues are congested or consolidated,
which may occur in patients who have pneumonia or a tumor.
Air in the pleural space causes a decreased fremitus.
DIF: Cognitive Level: Apply
REF: 210| 215| 218
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
Correct: These are functions of the upper airway.
Incorrect: 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: 193-194
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.
b.
c.
d.
e.
f.
Inspiratory wheezing found on auscultation
Hyperresonance heard on percussion
Decreased breath sounds heard on auscultation
Deceased diaphragmatic excursion on percussion
A sharp, abrupt pain reported when the patient breathes deeply
Decreased to absent vibration on vocal fremitus
ANS: B, C, D, F
Correct: These are all indications of enlargement or destruction of alveoli that occurs in
emphysema. Air is trapped, which increases the anteroposterior to lateral diameter creating a
barrel chest, and pushes the diaphragm down decreasing the excursion and causing
hyperresonance. The destroyed alveoli decrease the breath sounds and create absent vibration
on vocal fremitus.
Incorrect: Inspiratory wheezing found on auscultation indicates narrowed airways as found in
asthma. A sharp, abrupt pain reported when the patient breathes deeply is pleuritic chest pain
associated with pleural lining irritation that may occur in a patient with pleurisy or
pneumonia.
DIF: Cognitive Level: Analyze
REF: 207| 210-213| 215| 219
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body
Systems
3. On examination, a nurse finds the patient has a productive cough with green sputum and
inspiratory crackles. What other findings does this nurse expect during the examination?
Select all that apply.
a. Dull tones to percussion
b. Increased vibration on vocal fremitus
c. Fever
d. Decreased diaphragmatic excursion
e. A sharp, abrupt pain reported when patient breathes deeply
f. Muffled sounds heard when the patient says “e-e-e”
ANS: A, B, C, E
Correct: These abnormal findings are consistent with consolidation that may occur with
pneumonia.
Incorrect: Decreased diaphragmatic excursion occurs when the lung is overinflated as in
emphysema. Muffled sounds when the patient says “e-e-e” is an expected finding. With a
consolidation, the sound of “e-e-e” would be clear.
DIF: Cognitive Level: Analyze
REF: 198-199| 210-211| 215| 218
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body
Systems
4. A nurse is assessing the respiratory system of a healthy adult. Which findings does this nurse
expect to find? Select all that apply.
a. Thoracic expansion that is symmetric bilaterally
b. Respiratory rate of 24 breaths/min
c. Bronchophony revealing clear voice sounds
d. Breath sounds clear with vesicular breath sounds heard over most lung fields
e. Anteroposterior diameter of the chest about a 1:2 ratio of anteroposterior to lateral
f.
diameter
Symmetric thorax with ribs sloping downward at about 45 degrees relative to the
spine
ANS: A, D, E, F
Correct: These are expected findings from a lung and respiratory assessment of a healthy
adult.
Incorrect: 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: 204| 207-208| 210| 214| 217
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 1
packs of cigarettes a day for 14 years. The
nurse records this as _____ pack-years?
ANS:
21
1 packs of cigarettes  14 years = 21 pack-years.
DIF: Cognitive Level: Apply
REF: 197
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments