When performing a respiratory assessment on a patient, the nurse notices a costal angle of approximately 90 degrees. What should the nurse recognize about this finding? a. Observed in patients with kyphosis. b. Indicative of pectus excavatum. c. A normal finding in a healthy adult. d. An expected finding in a patient with a barrel chest.

When assessing a patient’s lungs, what should the nurse recall about the left lung? a. Consists of two lobes. b. Is divided by the horizontal fissure. c. Primarily consists of an upper lobe on the posterior chest. d. Is shorter than the right lung because of the underlying stomach.

During an assessment, the nurse knows that expected assessment findings in the normal adult lung include which findings? a. Adventitious sounds and limited chest expansion b. Muffled voice sounds and symmetric tactile fremitus c. Increased tactile fremitus and dull percussion tones d. Absent voice sounds and hyperresonant percussion tones

What are the primary muscles of respiration? a. Diaphragm and intercostals b. Sternomastoids and scaleni c. Trapezii and rectus abdominis d. External obliques and pectoralis major

The nurse is reviewing the technique of palpating for tactile fremitus with a new graduate. Which statement by the graduate nurse reflects a correct understanding of tactile fremitus? a. “Is caused by moisture in the alveoli.” b. “Is caused by sounds generated from the larynx.” c. “Reflects the blood flow through the pulmonary arteries.” d. “Indicates that air is present in the subcutaneous tissues.”

The nurse is observing the auscultation technique of a student nurse. What is the correct method to use when progressing from one auscultatory site on the thorax to another? a. Side-to-side comparison b. Top-to-bottom comparison c. Posterior-to-anterior comparison d. Interspace-by-interspace comparison

When auscultating the lungs of an adult patient, the nurse notes that low-pitched, soft breath sounds are heard over the posterior lower lobes, with inspiration being longer than expiration. How should the nurse interpret these findings? a. Normal sounds auscultated over the trachea. b. Bronchial breath sounds that are normal in that location. c. Vesicular breath sounds that are normal in that location. d. Bronchovesicular breath sounds that are normal in that location.

The nurse is auscultating the chest in an adult. Which technique is correct? a. Instructing the patient to take deep, rapid breaths b. Instructing the patient to breathe in and out through his or her nose c. Firmly holding the diaphragm of the stethoscope against the skin of the chest d. Lightly holding the bell of the stethoscope against the skin on the chest to avoid friction

The nurse is percussing over the lungs of a patient with pneumonia. If the patient has atelectasis, what sound will the nurse hear? a. Tympany b. Dullness c. Resonance d. Hyperresonance

When inspecting the anterior chest of an adult, the nurse should include which assessment? a. Diaphragmatic excursion b. Symmetric chest expansion c. Presence of breath sounds d. Shape and configuration of the chest wall

During an assessment of an adult, the nurse has noted unequal chest expansion and recognizes that this occurs in which situation? a. In an obese patient b. When part of the lung is obstructed or collapsed c. When bulging of the intercostal spaces is present d. When accessory muscles are used to augment respiratory effort

The nurse is listening to the breath sounds of a patient with severe asthma. Air passing through narrowed bronchioles would produce which of these adventitious sounds? a. Wheezes b. Bronchophony c. Bronchial sounds d. Whispered pectoriloquy

An adult patient with a history of allergies comes to the clinic complaining of wheezing and difficulty in breathing when working in his yard. The assessment findings include tachypnea, the use of accessory neck muscles, prolonged expiration, intercostal retractions, decreased breath sounds, and expiratory wheezes. What do these findings suggest? a. Asthma b. Atelectasis c. Lobar pneumonia d. Heart failure

The nurse is assessing the lungs of an older adult. Which of these changes are normal in the respiratory system of the older adult? a. Decrease in small airway closure occurs, leading to problems with atelectasis. b. Severe dyspnea is experienced on exertion, resulting from changes in the lungs. c. Respiratory muscle strength increases to compensate for a decreased vital capacity. d. Lungs are less elastic and distensible, which decreases their ability to collapse and recoil.

A 70-year-old patient is being seen in the clinic for severe exacerbation of his heart failure. Which of these findings is the nurse most likely to observe in this patient? a. Fever, dry nonproductive cough, and diminished breath sounds b. Rasping cough, thick mucoid sputum, wheezing, and bronchitis c. Productive cough, dyspnea, weight loss, anorexia, and tuberculosis d. Shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, and ankle edema

A patient has been admitted to the emergency department with a possible medical diagnosis of pulmonary embolism. The nurse expects to see which assessment findings related to this condition? a. Absent or decreased breath sounds b. Productive cough with thin, frothy sputum c. Chest pain that is worse on deep inspiration and dyspnea d. Diffuse infiltrates with areas of dullness upon percussion

What is the sac that surrounds and protects the heart is called? a. Myocardium b. Pericardium c. Endocardium d. Pleural space

The findings from an assessment of a 70-year-old patient with swelling in his ankles include jugular venous pulsations 5 cm above the sternal angle when the head of his bed is elevated 45 degrees. What does this finding indicate? a. Decreased fluid volume b. Increased cardiac output c. Narrowing of jugular veins d. Elevated pressure r/t heart failure

A 45-year-old man is in the clinic for a routine physical examination. During the recording of his health history, the patient states that he has been having difficulty sleeping. “I’ll be sleeping great, and then I wake up and feel like I can’t get my breath.” Which is the best response by the nurse? a. “When was your last electrocardiogram?” b. “It’s probably because it’s been so hot at night.” c. “Do you have any history of problems with your heart?” d. “Have you had a recent sinus infection or upper respiratory infection?”

The nurse is performing a cardiac assessment on a 65-year-old patient 3 days after her myocardial infarction (MI). Heart sounds are normal when she is supine, but when she is sitting and leaning forward, the nurse hears a high-pitched, scratchy sound with the diaphragm of the stethoscope at the apex. It disappears on inspiration. What does the nurse suspect? a. Another MI b. Increased cardiac output c. Inflammation of the precordium d. Ventricular hypertrophy resulting from muscle damage

When performing a cardiovascular assessment, what should the nurse understand about an S4 heart sound? a. Heard at the onset of atrial diastole b. Often a normal finding in the older adult c. Heard at the end of ventricular diastole d. Heard best over the second left intercostal space with the individual sitting upright

A 67-year-old patient states that he recently began to have pain in his left calf when climbing the 10 stairs to his apartment. This pain is relieved by sitting for “a couple of minutes”; then he is able to resume his activities. What do these symptoms suggest? a. Claudication b. Sore muscles c. Muscle cramps d. Venous insufficiency

A patient complains of leg pain that wakes him at night. He states that he “has been having problems” with his legs. He has pain in his legs when they are elevated that disappears when he dangles them. He recently noticed “a sore” on the outer aspect of the right ankle. What do these findings suggest? a. Pain r/t lymphatic abnormalities b. Problems r/t venous insufficiency c. Problems r/t arterial insufficiency d. Pain r/t musculoskeletal abnormalities

The nurse uses the profile sign during an assessment. What does this technique detect? a. Barrel chest b. Early clubbing c. Symmetry of the fingers d. Insufficient capillary refill

A patient has been diagnosed with venous stasis. Which of these findings would the nurse most likely observe? a. Unilateral cool foot b. Thin, shiny, atrophic skin c. Pallor of the toes and cyanosis of the nail beds d. Brownish discoloration to the skin of the lower leg

When auscultating over a patient’s femoral arteries, the nurse notices the presence of a bruit on the left side. Which statement about bruits is accurate? a. Often associated with venous disease b. Occur in the presence of lymphadenopathy c. Femoral artery bruits are caused by hypermetabolic states d. Occur with turbulent blood flow, indicating partial occlusion

During a visit to the clinic, a woman in her seventh month of pregnancy states that her legs feel “heavy in the calf” and that she often has foot cramps at night. The nurse notices that the patient has dilated, tortuous veins apparent in her lower legs. Which condition is reflected by these findings? a. Lymphedema b. Varicose veins c. Raynaud phenomenon d. Deep vein thrombophlebitis

When using a Doppler ultrasonic stethoscope, the nurse recognizes venous flow when which sound is heard? a. Low humming sound b. Swishing, whooshing sound c. Regular “lub, dub” pattern d. Steady, even, flowing sound

The nurse is assessing voice sounds during a respiratory assessment. Which of these findings indicates a normal assessment? (Select all that apply). a. As the patient says a long “ee-ee-ee” sound, the examiner hears a long “aaaaaa” sound. b. As the patient says a long “ee-ee-ee” sound, the examiner also hears a long “ee-ee-ee” sound. c. As the patient repeatedly says “ninety-nine,” the examiner clearly hears the words “ninety-nine.” d. Voice sounds are faint, muffled, and almost inaudible when the patient whispers “one, two, three” in a very soft voice. e. When the patient speaks in a normal voice, the examiner can hear a sound but cannot exactly distinguish what is being said.