Which statement by the nurse indicates the correct order of steps to take when performing a focused assessment of the respiratory system?

"I would palpate, inspect, percuss, and the auscultate.”

"I would percuss, palpate, auscultate, and then inspect.”

"I would auscultate, inspect, percuss, and then palpate."

"I would inspect, auscultate, palpate, and then percuss."

"I would inspect, palpate, percuss, then auscultate.”

Answer and Explanation

The Correct Answer is E

A. Palpate, inspect, percuss, and then auscultate is not the correct order, as inspection is always performed first.
B. Percuss, palpate, auscultate, and then inspect is incorrect, as inspection should come first.
C. Auscultate, inspect, percuss, and then palpate is also incorrect, as auscultation is typically the last step.
D. Inspect, auscultate, palpate, and then percuss is close but does not follow the standard order.
E. Inspect, palpate, percuss, then auscultate is the correct order for respiratory assessment, allowing for a thorough and systematic approach.

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Correct Answer is A

Explanation

A. A heave (or lift) often indicates ventricular hypertrophy or enlargement, suggesting increased workload on the heart.
B. Turbulent blood flow may lead to murmurs but is not specifically associated with a heave.
C. A persistently slow heartbeat is referred to as bradycardia and does not correlate with a heave.
D. An extreme pulse deficit relates to discrepancies between heartbeats and palpable pulses but is not linked to a heave.
E. Coronary artery blockage would not directly produce a heave; it typically leads to ischemic changes.

A. Right atrium B. Aorta C. Left ventricle D. Pulmonary vein E. Pulmonary artery F. Left atrium

Correct Answer is A,E,D,F,C,B

Explanation

Unoxygenated blood flows from the body into the right atrium, then passes through the pulmonary artery to the lungs. After receiving oxygen in the lungs, blood flows back to the heart via the pulmonary vein into the left atrium. It then moves into the left ventricle and is finally pumped out to the body through the aorta.

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Which statement by the nurse indicates the correct order of steps to take when performing a focused assessment of the respiratory system?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When performing a focused cardiac assessment on a newly admitted client, the nurse notes a heave on the left side of the chest. What can a heave signify?

Correct Answer is A

Explanation

Correct Answer is A,E,D,F,C,B

Explanation

A nurse is preparing to teach clients. Which client finding will cause the nurse to postpone a teaching session? (Select all that apply)

When auscultating the lungs of an adult client, the nurse notes that low-pitched, soft breath sounds are heard over the lower lobes. How would the nurse interpret these findings?

A client is admitted with a venous insufficiency of the right leg. What assessment findings does the nurse expect to find with this condition?

When performing a respiratory assessment on a patient, the nurse notices a costal vertebral angle (CVA) of approximately 160 degrees. How would finding?

The nurse is caring for a client admitted with pneumonia. The patient has a history of smoking 10 cigarettes per day for 30 years. What is the pack year amount? Use numbers only in your answer. No letters.

What subjective data should the nurse obtain about a client's respiratory status? Select all that apply.

A client with chronic cancer pain describes the pain as "sharp, tingling, with numbness. The nurse would document the pain as what?

The nurse obtains information when performing a focused assessment of a client with chronic obstructive pulmonary disease (COPD) who has been admitted with increasing dyspnea (shortness of breath) over the last 3 days. Which finding is most important to report to the health care provider?