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HEALTH ASSESSMENT EXAM 3 (RESPIRATORY) QUESTIONS AND ANSWERS
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HEALTH ASSESSMENT EXAM 3 (RESPIRATORY) QUESTIONS AND ANSWERS
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HEALTH ASSESSMENT EXAM 3(RESPIRATORY) QUESTIONS AND
ANSWERS
A respiratory pattern that gradually becomes faster and deeper than normal, then
slower, alternating with periods of apnea is known as which respiratory pattern?
A.) Cheyne-Stokes
B.) Tachypnea
C.) Kussmaul's
D.) Eupnea - Answer-A. Cheyne-Stokes respirations are described as respirations that
gradually become faster and deeper than normal, then slower, alternating with periods
of apnea. This pattern can be drug-induced, normal in frail elderly people while
sleeping, or a sign of impending death. Kussmaul's respiratory pattern is described as
faster and deeper respirations without pauses. Eupnea is normal respiratory rate and
rhythm. Tachypnea is an increased respiratory rate.
The thoracic cavity contains which of the following organs? Select all that apply.
A.) Most of the esophagus
B.) Pancreas
C.) Lungs
D.) Stomach
E.) Heart - Answer-E. Heart, C. Lungs, and A. Most of the Esophagus
The cavity contains the heart, lungs, thymus, distal part of the trachea, and most of the
esophagus. it does not contain the stomach or the pancreas.
An adult client comes to the clinic. The client is pale and diaphoretic, the respiratory rate
is 30 breaths/minute. Coarse crackles are noted in all lung fields. The client has smoked
for 40 years. Why is this client at increased risk for pneumonia? Select all that apply.
A.) Increased respiratory rate which impacts the amount of oxygen the client is able to
inhale.
B.) Decreased ability to cough up secretions because of weakened chest muscles.
C.) At great risk for "stiff lungs," which are harder to ventilate, because of his age.
D.) Increased risk for COPD because of years of smoking.
E.) Pooling of secretions because of decreased function of the cilia. - Answer-B, E, D,
and C. Decreased function of the cilia leads to the pooling of secretions in the lungs.
Weaker chest muscles also decrease the older person's ability to cough up secretions.
Thick, pooled secretions increase risks for pneumonia. The option pertaining to
increased respiratory rate is a distracter to the question.
What are the signs of hypoxia? Select all that apply.
A.) Respiratory rate > 30
B.) Cyanosis
C.) Increased level of consciousness
,D.) Retractions
E.) Use of accessory muscles to breathe
F.) Oxygen saturation of 90% - Answer-A, B, D, and E. A decreased level of
consciousness, respiratory rate > 30 breaths/min, oxygen saturation less then 90%,
cyanosis, retractions, and use of accessory muscle may indicate hypoxia.
A nurse is receiving report from the night shift about four clients. Which client would the
nurse see first?
A.) A 23-year-old woman who has a mountain biking accident in which she suffered a
neck fracture and now has numbness and tingling in her right arm.
B.) A 29-year-old woman with a history of drug abuse and a heart rate of 124 beats/min.
C.) A 57-year-old woman who has surgery yesterday for a small bowel obstruction with
possible wound dehiscence.
D.) A 64-year-old man with COPD who is short of breath and has a respiratory rate of
32 breaths/min. - Answer-D. Decreased level of consciousness, respiratory rate about
30 breaths/min, cyanosis, retractions, and use of accessory muscles may indicate
hypoxia (a medical emergency).
A client comes to the clinic and states, "I have a bad cold and am having trouble
breathing." The nurse checks the client's breath sounds and hears bilateral fine crackles
at the base. Of what is this finding indicative?
A.) Fluid in the bronchus
B.) No fluid present
C.) Fluid in the alveoli
D.) Fluid in the bronchioles - Answer-C. When fluid fills the alveoli, fine crackles may be
audible on auscultation. Excessive fluid in the alveoli may lead to airway collapse and
decreased breath sounds. Fine crackles are not indicative of fluid it the bronchioles or
bronchus or the absence of fluid in the lungs.
A client who just underwent hip replacement surgery reports pain at a 10 on a scale of 0
to 10 and receives 4 mg of morphine. A nurse on the orthopedic unit enters the client's
room and finds that the client has a respiratory rate of 7 breaths/min. the client is groggy
and hard to arouse. What could be contributing to the client's findings?
A.) Anesthesia, from surgery that morning
B.) Nothing, this is normal following surgery
C.) Opiates, which may cause hyperventilation
D.) Opiates, which may cause hypoventilation - Answer-D. Opiates may reduce the
ability of the brain to trigger breathing, causing hypoventilation (slow breathing). This
scenario does not describe a reaction to anesthesia, and it is not a normal finding
following surgery.
A nurse in the operating room has a client who just underwent gastric bypass surgery
and weighs 243 kilograms (534.6 pounds). Upon extubation, the client's oxygen
saturation drops to 84% and the client has difficulty catching her breath. What could be
causing these problems?
A.) Obesity, which can limit chest wall expansion and compromise breathing
, B.) A progressive loss of muscle function
C.) Pain, which is inhibiting the client's ability to breathe
D.) Anesthesia, which is causing the client to be sleepier than usual - Answer-A.
Extreme obesity can limit chest wall expansion (and thus compromise breathing).
Progressive loss of muscle function is related to disease such as muscular dystrophy,
not obesity. Pain and anesthesia would not be causes of decreased oxygen saturation
and breathing difficulty.
An adult client is brought to the ED by her daughter. The client is cyanotic; her pulse is
117 beats/min, respirations 36 breaths/min, blood pressure 100/64, and oxygen
saturation 82%. What is the first nursing action?
A.) Call a code
B.) Leave the client and daughter so as not to overexcite them
C.) Start an 18-guage IV
D.) Administer oxygen - Answer-D. If a client has acute shortness of breath, immediate
assessments include respiratory rate, pulse, blood pressure, and oxygen saturation.
The lungs are auscultated. Simultaneously, oxygen is administered, and inhalers may
be given. If the client is in bed, the head of the bed is elevated to reduce the effect of
gravity. Because anxiety increased the work of breathing, the nurse's role is to stay with
and to calm the client. Conversations should be limited while the nurse implements
interventions to improve oxygenation.
When caring for a client with chronic shortness of breath, fatigue is an issue. How might
the nurse limit fatigue and still gather assessment information needed for daily care?
A.) Spread care throughout the shift to allow rest periods
B.) Cluster care during times when the client is more rested
C.) Use shorter assessments
D.) Use more than one nurse to gather assessment data - Answer-B. In cases in which
fatigue limits the collection of assessment data, the nurse should consider clustering
care. Spreading care throughout the shift does not focus on times when the client feels
capable of handling activity. More than one nurse addresses potential nurse fatigue, not
client fatigue. Shorter assessment might not allow the nurse to gather crucial data.
A high-pitched crowing sound from the upper airways results from tracheal or laryngeal
spasm and is called what?
A.) Stridor
B.) Crackles
C.) Wheezes
D.) Rales - Answer-A. Stridor, a high-pitched crowing sound from the upper airway,
results from tracheal or laryngeal spasm. In severe laryngospasm, the larynx may
completely close off. This life-threatening emergency requires immediate medical
attention. Crackles, wheezes, and rales are adventitious breath sounds heard upon
auscultation of the lungs.
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