A nurse is performing a lung assessment on an older adult client and notes the following:

- Blood pressure: 136/90

- Pulse: 88 beats per minute

- Oxygen saturation: 92%

- Respiratory rate: 18 breaths per minute

- Lung sounds: Diminished breath sounds in all lung fields

What would the nurse expect to be happening with the client?

Client is experiencing a fluid deficit.

Adventitious sounds are present.

Hyperinflation of the lungs.

Client has a pectus carinatum.

Answer and Explanation

The Correct Answer is C

A. A fluid deficit may cause tachycardia and hypotension, but it does not directly cause diminished lung sounds.
B. Adventitious sounds (wheezes, crackles, rhonchi, etc.) are absent in this case. Diminished breath sounds suggest poor airflow, not abnormal sounds.
C. Hyperinflation of the lungs is correct. In conditions like chronic obstructive pulmonary disease (COPD) or emphysema, lung expansion is limited, leading to diminished breath sounds in all lung fields due to air trapping. The oxygen saturation of 92% is consistent with chronic lung disease.
D. Pectus carinatum (protrusion of the sternum) is a congenital deformity that does not cause diminished breath sounds.

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Correct Answer is B

Explanation

A. The left lower quadrant contains portions of the small and large intestines but is not the starting point for palpating the bladder.
B. The nurse should begin palpating at the symphysis pubis because the bladder is located in the lower abdomen. When distended, it rises above the pubic symphysis and can extend toward the umbilicus.
C. The right upper quadrant contains the liver and gallbladder but is not relevant to bladder assessment.
D. A significantly distended bladder may extend above the umbilicus, but the nurse should begin palpation at the symphysis pubis and move upward to assess for distention.

A. The right lung is approximately one third larger than the left lung. B. The lower lobes of both lungs are primarily located toward the anterior chest wall. C. The right lung has three lobes, while the left lung has two lobes. D. The lungs are structurally symmetrical but functionally different.

Correct Answer is C

Explanation

A. The right lung is larger than the left to accommodate the heart’s position, but it is not precisely one third larger.
B. The lower lobes of both lungs are primarily located toward the posterior chest wall, not the anterior. When auscultating breath sounds in the lower lobes, the nurse should focus on the posterior thorax.
C. The right lung has three lobes (upper, middle, and lower), while the left lung has two lobes (upper and lower). This anatomical difference is important for respiratory assessment and auscultation.
D. The lungs are not structurally symmetrical; the left lung is smaller due to the cardiac notch. While there are minor functional differences, the primary distinction is anatomical.

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Naxlex Comprehensive Predictor Exams

A nurse is performing a comprehensive abdomen assessment including inspection, auscultation, and palpation. Upon palpation, the client's bladder is found to be distended. What location would the nurse begin palpating for the distended bladder?

Correct Answer is B

Explanation

The nurse is preparing to perform a focused respiratory assessment on a client. The nurse should be cognizant of what anatomical characteristic of the lungs?

Correct Answer is C

Explanation

The nurse is inspecting a new client's abdomen and notes the presence of a tight, distended abdomen and visible arterioles on the abdominal skin surface. What would the nurse do next?

An older adult client reports that they are experiencing severe trunk pain and is concerned that it might be shingles. Which type of lesion would the nurse most likely assess if shingles were present?

The nurse identifies that the patient care tech recorded the client's blood pressure as 78/52. The nurse recognizes this blood pressure is abnormally low for this client. What is the best response by the nurse?

After teaching a group of students about changes in body weight due to aging, the instructor determines that the students have understood the teaching when they state which of the following?

While auscultating a client's trachea, the nurse hears a high, harsh sound with short inspiration and long expiration. How would the nurse document this finding?

While assessing a client's abdomen, the nurse observes sharp pains and involuntary reflex guarding on expiration. What complication does the nurse suspect based on these findings?

A nurse has completed the client's initial assessment and is preparing to identify abnormal data and the client's strengths. Which of the following is required to successfully complete this phase of the nursing process?