Question

2. During an assessment of the lungs and thorax of an adult client with no history of lung diseases, a nurse should consider which of the fallowing-----: A. muffles voice sounds and symmetric tactile fremitus B. adventitious and limited chest expansions C. increased tactile fremitus and dull percussion tones D. absent voice sounds and hyper resonant percussion tones

23. When preforming a respiratory assessment on an adult client, a nurse auscultates moist, popping sounds during the inspiratory phase of------- adventitious sounds as: A. friction rub B. crackles C. wheezing D. bronchophony

24. A nurse is auscultating the aortic area of the chest and knows it is located in the fallowing site: A. 4-5TH intercostal space left of the sternal border B. 2nd intercostal space left of the sternal border C. 5th intercostal space medial to mid-clavicular line D. 2nd intercostal space right of the sternal border

26. A client presents to the emergency room with difficultly breathing. The nurse preforming the assessment would expect to find? A. rhonchi in upper lobes that clear with coughing B. pulse oxygen of 93% C. use of accessory abdominal muscles D. respiratory rate of 22

27. Which of the fallowing should a nurse expect to asses for a client with a history of chronic obstructive pulmonary disease? A. barrel chest B. unequal chest expansion C. oxygen saturation level 99% D. increased tactile fremitus

28. A nurse is preparing to asses a client who is experiencing significant shortness of breath. How should the nurse procced with the assessment? A. examine the lungs and thorax prior to preforming a complete assessment B. obtain thorough history and physical assessment information from the client’s family C. ask the client to lie down to obtain an accurate cardiac and respiratory assessment D. preform a complete history and physical assessment to obtain a baseline

29. Which of the fallowing should the nurse preform to assess the arterial function of lower extremities? A. palpating the pedal pulses B. humans sign C. Allen’s test D. assess medial malleoli for edema

30. When assessing the carotid arteries of an older client with cardiovascular disease a nurse should? A. palpate both arteries simultaneously to compare amplitude B. palpate each artery in the upper one third of the neck C. instruct the client to take a slow deep breathe during auscultation D. auscultate with the bell of the stethoscope to assess for bruits

Answer 1

First question- Option A

Option A- To assess the functioning of normal tissue without any history of lung diseases- the nurse will ask the patient to say 99 and listen to the sound using a stethoscope, which will be muffled and faint if there aren't any abnormalities. And also, the finding says symmetric (equal) tactile fremitus- no abnormalities/ palpations.

Option B- Adventitious sounds represnt any crackles, rhonchi, or wheezes etc which indicate any obstruction of trachea or larynx. And also, limited chest expansion is mentioned.

Option C- indicates inflammed lung tissue and chances of pneumonia. Dull percussion tones are heard when a tissue is inflammed.

Option D- absent sounds mean fluid build up around the lungs. Hyper resonant percussion tones are heard when lungs are hyperventilated with air.

All the other three (options B,C,D) should the considered when underlying diseases are suspected.

23. Option- B

Crackles are described as moist/wet popping sounds.

While, wheezing is a squeaky noise; friction rub is a non-musical explosive sound.

Bronchopony indicates consolidation of lung.

24. Option D is the location of the aortic area.

26. Option C- Use of accessory abdominal muscles is seen when there is any abnormality or labored breathing pattern. The other options- 93% oxygen saturation, 22 Respiratory rate( within normal range) and rhonchi that resolves after coughing doesnt cause any difficulty in breathing.

27. Option A- In later stages of COPD, lungs get overinflated with air causing barrel chest.

Bilateral decreased chest expansion is seen in COPD but not as what described in option B. And, as in option D the tactile fremitus is decreased in COPD. In COPD, abnormality is decrease in oxygen saturation below 90 %.

28. Option A- Examining the lungs and thorax prior to preforming a complete assessment is the first step to be considered before any further assessment.

29. Option A- assessing pedal pulse is to check the PAD, i.e disease of the narrowing of arteries that supply blood to the lower extremities.

B- its homans test but not humans test which is used to test mobility of wrist and ankle.

C- Allen's test is used to assess the arterial blood supply of hand but not lower extremities.

D- to assess medial malleoli is to determine the extent of pitting edema.

30. Option D as it helps to assess the risk of the elderly to CVD, any stenosis.

A- both arteries cannot be palpated simultaneously as they increase pressure in baroreceptors, B- to check whether any clogged artery in your neck.