Assessment Respiratory and Upper Respiratory
problem Lewis Exam With Questions And Verified
Detailed Answers 2024-2025
The patient is admitted to the hospital with acute shortness of breath. Which of the
following nursing interventions is appropriate when initially assessing this patient?
A) Have the patient lie down so a complete physical assessment can be conducted.
B) Rapidly interview the patient about this episode of respiratory distress.
C) Complete the admission database to determine any allergies before beginning
treatment.
D) Delay the physical examination until after the pulmonary function tests have been
completed. - ANSWER ANS: B
If the patient is in severe respiratory distress, only information pertinent to the current
problem is collected and a thorough assessment is delayed until a later time. There is no
indication to collect a complete health history or to conduct a complete physical
examination until the patient is out of acute distress. A brief questioning and focused
physical assessment must be performed efficiently to help determine the etiology of the
distress and to imply treatment. Allergy assessment is part of this, but it is not the time
to complete a full admission database. The initial respiratory assessment does need to
be completed before ordering diagnostic tests or interventions.
The nurse prepares a patient with a left-sided pleural effusion for a thoracentesis. How
should the nurse position the patient?
A) Supine with the head of the bed elevated 30 degrees
B) In a high-Fowlers position with the left arm extended
C) On the right side with the left arm extended above the head
D) Sitting upright with the arms supported on an over bed table - ANSWER ANS: D
The upright position, arms supported, with increased lung expansion allows fluid to
collect at the lung bases and expands the intercostal space for easier access to the
pleural space. Each of the other positions would increase the work of breathing for the
patient and would make access to the pleural space more cumbersome for the health
,care provider performing the thoracentesis.
While auscultating a patient's lungs, the nurse detects low-pitched, bubbling sounds
that occur during inspiration to the lower third of both lungs. The nurse should
document this finding as which of the following? a) Inspiratory crackles at the bases b)
Expiratory wheezes in both lungs c) Abnormal lung sounds in the apices of both lungs d)
Pleural friction rub in the right and left lower lobes - ANSWER ANS: A
Crackles are low-pitched, bubbling sounds usually heard on inspiration. Wheezes are
high-pitched sounds. They can be heard during the expiratory or inspiratory phase of
the respiratory cycle. The lower third of both lungs are the bases, not apices. Pleural
friction rubs are grating sounds that are usually heard during both inspiration and
expiration.
The patient says 99 while the nurse palpates the posterior chest and notes absent
fremitus. The nurse should next
A). Palpate the anterior chest and observe for barrel chest.
B). Encourage the patient to turn, cough, and deep breathe.
C). Review the chest x-ray report for evidence of pneumonia.
D). Auscultate anterior and posterior breath sounds bilaterally. - ANSWER ANS: D
Tactile fremitus is assessed by placing the palms of the hands on the chest and asking
the patient to repeat a word or phrase such as 99. After the nurse has identified absent
fremitus, the nurse listens for breath sounds over the lungs to establish if breath sounds
are present or absent. The nurse may find that fremitus is absent in the case of
pneumothorax or atelectasis. Conditions such as pneumonia, lung tumors, thick
bronchial secretions, and pleural effusion create increased vibration. Appropriate
intervention for atelectasis includes measures such as turning, coughing, and deep
breathing, but the nurse must first auscultate breath sounds. Fremitus is decreased if
the hand is over a hyperinflated lung or further away from the lung (barrel chest).It is
more difficult to palpate fremitus on the anterior chest because of the greater muscles
and breast tissue.
A patient is receiving a bronchoscopy for a chronic cough. Which is the best action by
the nurse after this procedure?
A) Elevate the head of the bed to 80 to 90 degrees.
B) Keep the patient NPO until the gag reflex returns.
, C) Place on bed rest for at least 4 hours after bronchoscopy.
D) Notify the health care provider about blood-tinged mucus. - ANSWER ANS: B
Risk for aspiration and maintaining an open airway is the priority. Because a local
anesthetic is used to suppress the gag/cough reflexes during bronchoscopy, the nurse
should watch for the return of these reflexes before permitting the patient to take oral
fluids or food. Blood-tinged mucus is not uncommon after bronchoscopy. There is no
need to keep the patient on bed rest and there is no need for the head of the bed to be in
the high-Fowlers position.
The nurse is performing a shift assessment on a patient who was admitted in the early
stage of heart failure. While auscultating this patient's lungs, which of the following
breath sounds would the nurse most likely auscultate?
A) Continuous rumbling, snoring, or rattling sounds primarily on expiration
B) Continuous high-pitched musical sounds during inspiration and expiration
C) Discontinuous, high pitched sounds of short duration heard on inspiration
D) A sequence of long-duration, discontinuous, low-pitched sounds on inspiration -
ANSWER ANS: C
The early phase of heart failure is likely to present fine crackles. Fine crackles are the
short-duration discontinuous, high-pitched sounds that are usually heard during
inspiration. Rhonchi are the continuous rumbling, snoring, rattling sounds mainly in
expiration. Coarse crackles are successive, long-duration, discontinuous low-pitched
inspiratory sounds. Wheezes are the continuous high-pitched musical sounds during
inspiration and expiration.
During a care activity for a patient who has a respiratory disease, the nurse finds that
the patients SpO2 drops from 93% to 88% while ambulating in the hall. Which is the
nurse's priority action?
A) Notify the health care provider.
B) Document the response to exercise.
C) Administer the PRN supplemental O2.
D) Encourage the patient to pace activity. - ANSWER ANS: C
The desaturation to 85% indicates this is a hypoxemic patient who would need
supplemental oxygen during exercise. The other interventions are not wrong, but
correction of hypoxemia must be the first intervention taken.
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