Respiratory Assessment Flashcard

Front

A 70-year-old client presents with dyspnea and orthopnea. Which assessment finding most likely indicates left-sided heart failure?

Back

Inspiratory crackles in bilateral lower lobes

Answer explanation

Rationale: Crackles suggest fluid backing up into the lungs, typical in left-sided heart failure. Right-sided heart failure causes peripheral edema and JVD

Front

A nurse auscultates coarse crackles in the posterior lower lobes. What condition is most consistent with this finding?

Back

Pulmonary edema

Answer explanation

Rationale: Coarse crackles are associated with fluid in the lungs, such as in pulmonary edema.

Front

During a respiratory assessment, the nurse percusses hyperresonance over the left lung field. What is the likely cause?

Back

Pneumothorax

Answer explanation

Rationale: Hyperresonance occurs when there is extra air, such as in pneumothorax

Front

A patient is using accessory muscles and has nasal flaring. What priority action should the nurse take?

Back

Notify the healthcare provider immediately

Answer explanation

Rationale: Use of accessory muscles and nasal flaring indicate respiratory distress.

Front

Which assessment technique is most effective for identifying consolidation in the lungs? Options: Inspection, Percussion, Tactile fremitus, Palpation of tracheal deviation

Back

Tactile fremitus

Answer explanation

Rationale: Increased fremitus indicates denser tissue, such as consolidation.

Front

Which respiratory pattern is most commonly associated with diabetic ketoacidosis? Options: Cheyne-Stokes, Biot’s respirations, Kussmaul respirations, Apneustic breathing

Back

Kussmaul respirations

Answer explanation

Rationale: Kussmaul breathing is rapid, deep breathing seen in metabolic acidosis (e.g., DKA).

Front

A nurse auscultates diminished breath sounds in the right lower lobe. What condition is most likely?

Back

Effusion

Answer explanation

Rationale: Fluid in the pleural space dampens sound transmission.

Front

Which finding should the nurse report immediately? Options: Respiratory rate of 22/min, SpO₂ of 88% on room air, Symmetrical chest expansion, Vesicular breath sounds

Back

SpO₂ of 88% on room air

Answer explanation

Rationale: This indicates hypoxia and requires prompt action.

Front

In assessing for clubbing, what area should the nurse inspect? Fingertips, Nail beds, Toes, Lower legs

Back

Nail beds

Answer explanation

Rationale: Clubbing involves the angle of the nail bed due to chronic hypoxia.

Front

A nurse notes tripod positioning in a patient with COPD. What does this indicate?

Back

Increased respiratory effort

Answer explanation

Rationale: Tripod positioning helps increase lung expansion during respiratory distress.