Chapter 27

Assessment: Respiratory System

Answer Keys for Questions

• Rationales for Bridge to NCLEX Examination Questions

1. Correct answer: a

Rationale: The carina is the anatomic landmark that separates the upper respiratory tract from

the lower respiratory tract. The larynx, epiglottis, and trachea are all above the carina (part of the

upper respiratory tract).

2. Correct answer: d

Rationale: During inspiration, the diaphragm contracts, moves downward, and increases

intrathoracic volume. At the same time, the external intercostal muscles and scalene muscles

contract, increasing the lateral and anteroposterior dimension of the chest. This causes the size of

the thoracic cavity to increase and intrathoracic pressure to decrease. As a result, air is pulled

into the lungs.

3. Correct answer: c

Rationale: The ability of the lungs to oxygenate arterial blood adequately is determined by

examination of the partial pressure of oxygen in arterial blood (PaO2) and arterial oxygen

saturation (SaO2). The heartrate, hemoglobin level, and mean arterial pressure do not help

evaluate oxygenation. PaCO2 evaluates the ventilation portion.

4. Correct answers: a, b, c, d

Rationale: Respiratory defense mechanisms are efficient in protecting the lungs from inhaled

particles, microorganisms, and toxic gases. These include the cough reflex, mucociliary

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escalator, reflex bronchoconstriction, and alveolar macrophages. The alveolar capillary

membrane is not part of the respiratory defense mechanism.

5. Correct answers: a, b, d

Rationale: Arterial blood gases (ABGs) are measured to determine oxygenation status,

ventilation status, and acid-base balance. ABG analysis includes measurement of the partial

pressure of oxygen in arterial blood (PaO2), partial pressure of carbon dioxide in arterial blood

(PaCO2), acidity (pH), bicarbonate (HCO3–), and arterial oxygen saturation (SaO2) in arterial

blood. Mixed venous O2 saturation is the measurement of O2 saturation in venous blood.

Compliance is the lung’s ability to expand and resistance is the ease of airflow in and out of the

lungs. They cannot be determined with ABGs.

6. Correct answer: b

Rationale: Early symptoms of inadequate oxygenation include unexplained restlessness,

apprehension, and irritability. Dyspnea, hypotension, bradycardia, cyanosis, cool and clammy

skin are late signs.

7. Correct answers: c, d, e

Rationale: The anterior-posterior diameter of the thoracic cage and the residual volume increase

in older adults. An older adult has a less forceful cough. The costal cartilages calcify with aging

and interfere with chest expansion. Decreased breath sounds at the base of lungs is also a

common finding in older adults.

8. Correct answers: b, d, e

Rationale: Important parts of the subjective respiratory assessment include dyspnea during

exercise or at rest, what medications they are currently taking, and their ability to sleep at night.

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The date of the last chest x-ray and pulmonary function test (PFT) results are all objective

measures of assessment.

9. Correct answer: b

Rationale: Normally, auscultation should proceed from the lung apices to the bases so that

opposite areas of the chest are compared. For the patient in mild respiratory distress, start at the

bases. The patient may not be able to breathe through the nose with the mouth closed, and, there

is no sign that the patient needs immediate intubation.

10. Correct answer: d

Rationale: Bronchial or bronchovesicular sounds heard in the peripheral lung fields would be

abnormal. All the other assessment findings are considered normal.

11. Correct answer: a

Rationale: Thoracentesis is the insertion of a large-bore needle through the chest wall into the

pleural space to obtain specimens for diagnostic evaluation, remove pleural fluid, or instill

medication. A paracentesis is removal of fluid from the abdomen.

• Answer Guidelines for Case Study on in the text.

1. What are the possible causes of F.T.’s shortness of breath?

COPD exacerbation, asthma exacerbation, heart failure, pneumonia, pleural effusion, fluid

overload, pulmonary embolus

2. Does F.T. need to be admitted to hospital, or is his condition stable and he can be seen by an

HCP in a few hours?

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F.T. needs admission to the hospital. He may not be able to wait “a few hours” later to be seen.

The HCP would be reasonably prudent to check on and reassess F.T. frequently and expedite

access to a respiratory specialty HCP should his current condition worsen.

3. What questions would be a priority during the subjective assessment?

Questions that would take priority during the subjective assessment would relate to the current

condition that the patient has. These questions may include:

• When did you first start feeling sick?

• Are you short of breath right now?
• Are you having any pain with breathing?
• Does anything make your breathing better? Worse?
• Are you taking all your medications as prescribed? Are you using your inhalers?
• Has your condition gotten better or worse over the past 2 to 3 days?

Subjective Data

1. Of the information provided, which subjective assessment findings concern you most?

“He thinks he caught a cold from his granddaughter,” more short of breath than normal; not

eating and drinking over the past 2 to 3 days; has decreased mobility; and is not sleeping due to

the breathing problems. He is voiding small amounts of dark, amber urine, which suggests

dehydration.

2. From the information provided from F.T., what other information would you ask him about

his condition (time permitting)?

Once initial questions about the patient’s current condition have been asked, the HCP may ask

other questions relevant to F.T. These questions may be asked only after you have assessed that

F.T. is not in need of immediate medical attention due to his breathing difficulty. Examples of

questions that may be asked later during the subjective assessment include:

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 • What medical problems do you have? What medical problems are you currently being

treated for? What medications do you take for your medical problems? Do you take any

nonprescription or illicit medications?

• How well do your medications typically control your breathing?

• Do you smoke?

• Have you ever smoked? If you quit, how long ago?

• Have you had a flu vaccine this year?

• Have you recently been exposed to anyone with an upper respiratory infection?

• Have you had a Pneumovax vaccine?

• Before this incident, how far could you typically walk without getting short of breath?

• Before this incident, how many steps could you typically walk up without getting short of

breath? How many pillows do you need to sleep with?

• Do you sleep lying down or sitting up?

• How many hours of sleep do you typically get each night?

• Do you have any anxiety related to the shortness of breath?

• Are you under any stress that may be contributing to your shortness of breath?

3. What type of assessment would be most appropriate for F.T.: comprehensive, focused, or

emergency?

Because F.T. is not acutely unstable, a focused assessment is appropriate to identify the

cause of his dyspnea.

4. F.T. cannot use his inhaler appropriately while he is talking with you. Is this an

appropriate time to teach him about the proper use of his inhaler?

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F.T. will be focused on his breathing difficulty. The HCP will need to carefully assess the

situation and may need to help him prime and get the inhaler to his mouth should he become

short of breath during the assessment. Patient teaching is ongoing and can always be completed

once the patient’s primary condition has been addressed and stabilized.

5. What will you include in the physical assessment? What would you think will be

priorities in your physical assessment?

• Vital signs (temperature, pulse rate, respiratory rate, BP)

• Oxygen saturation (SpO2)

• Observe for manifestations of heart failure (peripheral edema, jugular venous distention)

• Observe skin color, use of accessory muscles (including mouth and abdominal breathing),

position of comfort for breathing, chest expansion, respiratory pattern

• Assess nails for clubbing

• Auscultate heart and lung sounds

• Priorities in the physical examination include: vital signs, measuring oxygen

saturation, observing for use of accessory muscles, asking if he has any difficulty

breathing, and auscultating lungs sounds.

Objective Data

Physical Assessment

1. What physical assessment findings concern you most?

• Increased temperature, increased pulse rate, increased respiratory rate, increased BP

• Irregular pulse

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• Decreased SpO2

• Accessory muscle use while breathing

• Edema of the hands, lower legs, and feet (bilaterally)

• Fine crackles at lung apices; decreased air entry with coarse crackles at lung bases

• Productive cough with yellow-tinged sputum

2. Identify 3 interventions that may be implemented immediately.

Starting low-flow oxygen; obtaining a chest x-ray, blood work, and a sputum sample; starting IV

therapy

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3. With F.T.’s physical assessment information, what diagnostic studies would you expect to be

ordered?

CBC, basic metabolic panel, BNP (b-type natriuretic peptide), chest x-ray, 12 lead ECG, sputum

for gram stain and culture and sensitivity, arterial blood gas analysis (ABG). Depending upon

his response to treatment, a bedside echocardiogram may be ordered.

Objective Data

Diagnostic Studies

1. Which diagnostic results concern you most?

Of all the diagnostic tests, the tachycardia, elevated WBC count, low serum potassium, and

the abnormal chest x-ray are of most concern.

2. What do you think is the cause of F.T.’s problems?

The most likely cause of F.T.’s respiratory problems is pneumonia, accompanied by

exacerbation of heart failure (tachycardia, low urinary output) and hypokalemia.

3. What patient teaching can you do with F.T. as he is waiting to be admitted to the

hospital?

Explain to F.T. the reason for hospitalization and the need for oxygen therapy. F.T. will need

IV antibiotic therapy and potassium supplementation, so you may do patient teaching on the

antibiotic he is receiving and the importance of potassium. Tell him to report if there is any

change in his breathing, any dizziness, lightheadedness, or change in characteristics of sputum

(including presence of any blood).

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 4. What is the interprofessional team’s top priority for F.T. at this time?

The top priority is maintaining patency of F.T.’s airway, monitoring for any deterioration in

condition, obtaining the sputum specimen for culture as quickly as possible, starting a broad

spectrum antibiotic, resolving hypokalemia, arranging for admission to hospital, and notifying

his family.

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