HA Chapter 16

B. Airway patency

When the nurse assesses a 78-year-old patient with pneumonia, what is the priority assessment?

A. Breath sounds

B. Airway patency

C. Respiratory rate

D. Percussion sounds

A. Chest pain

A 45-year-old male has been admitted to the hospital with suspicion of PE. Which of the following symptoms should the nurse report to the primary health practitioner immediately?

A. Chest pain

B. Shortness of breath

C. Respirations 20 breaths/min

D. Productive cough

A. Increased wheezing

D. Oxygen saturation 90%

A 62-year-old female comes to the clinic with an exacerbation of asthma. Which of the following findings indicate a diagnosis of asthma? Select all that apply.

A. Increased wheezing

B. Coarse rhonchi

C. Fever T 38°C orally

D. Oxygen saturation 90%

D. Emergency

A 3-year-old child is brought to the ED with stridor, nasal flaring, intercostal and supraclavicular retractions, and respiratory rate of 40 breaths/min. What type of situation is this?

A. Stable

B. Acute

C. Urgent

D. Emergency

A. Impaired breathing

A 92-year-old female with a history of COPD presents with increasing shortness of breath, wheezing, no sputum, and 5-lb weight gain in 1 week. What is the most likely problem?

A. Impaired breathing

B. Impaired airway clearance

C. Activity intolerance

D. Overweight

C. Tobacco smoking

Which of the following factors is the most significant risk factor for COPD?

A. Increased age

B. Immune suppression

C. Tobacco smoking

D. Occupational exposure

B. Dyspnea

When the nurse assesses a client with respiratory symptoms, which of the following complaints should be evaluated first?

A. Chest soreness

B. Dyspnea

C. Cough

D. Sputum

A. Shortness of breath

B. Decreased breath sounds

C. Decreased oxygen saturation

D. Increased tactile fremitus

When assessing a patient with atelectasis, what assessment findings are expected? Select all that apply.

A. Shortness of breath

B. Decreased breath sounds

C. Decreased oxygen saturation

D. Increased tactile fremitus

E. Hyperresonance

B. Vesicular breath sounds, O2 saturation 96%, pink

Which assessment findings would indicate that inhaled bronchodilators have been effective?

A. Expiratory wheezing, O2 saturation 94%, pallor

B. Vesicular breath sounds, O2 saturation 96%, pink

C. Bronchial breath sounds, O2 saturation 100%, erythema

D. Crackles, O2 saturation 90%, circumoral cyanosis

B. a normal finding over the bronchi.

The nurse auscultates bronchovesicular breath sounds in the second ICS near the sternum. The nurse interprets this as

A. a normal finding over the trachea.

B. a normal finding over the bronchi.

C. an abnormal finding over the lung.

D. an abnormal finding over the trachea.