ch 11. questions
During the problem-based history, a patient reports coughing up sputum when lying on the right side, but not when lying on the back or left side. The nurse suspects this patient may have a lung abscess. What additional question does the nurse ask to gather more data?
"Does the sputum have an odor?" Sputum with odor and sputum production with change of position is associated with lung abscess or bronchiectasis. Chest pain on deep breathing is associated with pleural lining irritation. Tightness in the chest is associated with asthma. Coughing up rust-colored sputum is associated with pneumonia, but coughing up blood may be associated with lung cancer.
Which question will give the nurse additional information about the nature of a patient's dyspnea?
"How has this condition affected your day-to-day activities?" B provides data about the severity of the dyspnea and what actions the patient has taken to cope with the dyspnea on a daily basis.
A patient tells the nurse that he has smoked packs of cigarettes a day for 14 years. The number of packs the nurse should record in the medical record is ___ pack-years.
21 packs of cigarettes 14 years = 21 pack-years.
After taking a brief health history, a nurse needs to complete a focused assessment on which patient?
A male who works as a painter. The fumes and chemicals from the paint may expose the patient to respiratory irritants. A baseline pulmonary assessment needs to be documented. Other patients are not at risk for pulmonary disease.
40 20X2
A patient tells the nurse that she has smoked 2 packs of cigarettes a day for 20 years. The nurse records this as how many pack-years?
A nurse examines a patient with a pleural effusion and finds decreased fremitus. What additional abnormal finding should the nurse anticipate during further examination?
Absent breath sounds in the affected area Absent breath sound in the affected area is anticipated because the fluid in the pleural space prevents breath sounds from being heard.
A nurse auscultates low-pitched, coarse snoring sounds in a patient's lungs during inhalation. What is the most appropriate action for the nurse to take at this time?
Ask the patient to cough and repeat auscultation. The sounds indicate rhonchi, or secretions in the bronchi. The first action to take is to determine if the rhonchi clear with coughing. If the rhonchi clear, there is no need to further investigate this finding
During a symptom analysis, a patient describes his productive cough and states his sputum is thick and yellow. Based on these data, the nurse suspects which factor as the cause of these symptoms?
Bacteria Bacteria usually produce sputum that is yellow or green in color. A virus usually produces a nonproductive cough. An allergy usually produces clear sputum. A fungus usually produces few symptoms. The sputum used to diagnose the fungus is obtained from tracheal aspiration rather than the patient coughing up the sputum.
A patient complains of shortness of breath and having to sleep on three pillows to breathe comfortably at night. During the nurse's examination, what findings will suggest that the cause of this patient's dyspnea is due to heart disease rather than respiratory disease?
Bilateral peripheral edema Bilateral peripheral edema indicates heart failure; dyspnea occurs because the heart cannot adequately perfuse the lungs.
A nurse palpating the chest of a patient finds increased fremitus bilaterally. What is the significance of this finding?
Bilateral pneumonia Increased fremitus occurs when lung tissues are congested or consolidated, which may occur in patients who have pneumonia or a tumor. An increase in fremitus from normal is not an expected finding
A patient has right lower lobe pneumonia, creating a consolidation in that lung. In assessing for vocal fremitus, the nurse found increased fremitus over the right lower lung. What finding does the nurse anticipate when assessing vocal resonance to confirm the consolidation?
Bronchophony reveals the patient's spoken "99" as clear and loud. is an abnormal finding and occurs in consolidation
A nurse inspects a patient's hands and notices clubbing of the fingers. The nurse correlates this finding with what condition?
Chronic hypoxemia Clubbing develops due to chronic hypoxemia, which occurs in chronic obstructive pulmonary disease
A nurse is assessing a patient who was diagnosed with emphysema and chronic bronchitis 5 years ago. During the assessment of this patient's integumentary system, what finding should the nurse correlate to this respiratory disease?
Clubbing of the fingers Clubbing of the fingers develops due to chronic hypoxemia, which occurs in chronic obstructive pulmonary disease
What are the functions of the upper airways? (Select all that apply.)
Conduct air to lower airway,Prevent foreign matter from entering respiratory system,Warm, humidify, and filter air entering lungs. Options A, C, and D are functions of the upper airway. Gas exchange occurs in the alveoli. The cardiovascular system provides transportation of oxygen and carbon dioxide between alveoli and cells.
In reviewing the patient's record, the nurse notes that the patient has air in the subcutaneous tissue. The nurse validates that this patient has crepitus with which finding?
Crackling sensation under the skin of the chest on palpation A crackling sensation is the finding when crepitus is present
On inspection, a nurse finds the patient's anteroposterior diameter of the chest to be the same as the lateral diameter. Based on this finding, what additional data does the nurse anticipate?
Decreased breath sounds on auscultation The equal anteroposterior and lateral diameters of the chest indicate air trapping from enlarged or destroyed alveoli. This air trapping causes decreased to absent breath sounds on auscultation
A nurse in the emergency department is assessing a patient with a moderate left pneumothorax. What does this nurse expect to find during the respiratory examination?
Distant to absent breath sounds over the left chest The air separating the lung from the chest where the nurse is auscultating creates distant to absent breath sounds
On examination, a nurse finds the patient has a productive cough with green sputum and inspiratory crackles. What other findings does this nurse expect during the examination? (Select all that apply.)
Dull tones to percussion, Increased vibration on vocal fremitus,Fever,A sharp, abrupt pain reported when patient breathes deeply The abnormal findings of options A, B, C, and E are consistent with consolidation that may occur with pneumonia
A patient is admitted to the emergency department with a tracheal obstruction. What sound does the nurse expect to hear as this patient breathes?
High-pitched sounds on inspiration and exhalation High-pitched sounds on inspiration and exhalation are consistent with stridor
A nurse is auscultating the lungs of a healthy male patient and hears crackles on inspiration. What action can the nurse take to ensure this is an accurate finding?
Hold stethoscope firmly to prevent movement when placed over chest hair. The stethoscope moving even slightly on chest hair can mimic the sound of crackles
On inspection, the nurse finds the patient's anteroposterior diameter of the chest to be the same as the lateral diameter. What other findings does this nurse expect during the examination? (Select all that apply.)
Hyperresonance heard on percussion, Decreased breath sounds heard on auscultation,Deceased diaphragmatic excursion on percussion,Decreased to absent vibration on vocal fremitus Options B, C, D, and F are all indications of enlargement or destruction of alveoli that occurs in emphysema. Air is trapped, which increases the anteroposterior to lateral diameter creating a barrel chest, and pushes the diaphragm down decreasing the excursion and causing hyperresonance
A patient reports a productive cough with yellow sputum, fever, and a sharp pain when taking a deep breath to cough. Based on these data, what abnormal finding will the nurse anticipate on examination?
Increased tactile fremitus and dull percussion tones The data describe purulent sputum and inflammation of the pleura that may occur in pneumonia. Additional findings include increased tactile fremitus and dull percussion tones, indicating congested or consolidated lung tissues
Where does a nurse expect to hear bronchovesicular lung sounds in a healthy adult?
Near the sternal border Bronchovesicular breath sounds are normally heard over the central area of the anterior thorax around the sternal border. Vesicular breath sounds are normally heard in the lower lobes. Bronchial sounds are normally heard over the trachea. Vesicular breath sounds are normally heard in the apices of the lungs.
A nurse notices a patient's chest wall moving in during inspiration and out during expiration. What additional assessment must the nurse perform immediately?
Palpate for tracheal deviation. Chest wall moving in during inspiration and out during expiration is paradoxical chest wall movement. It can be caused by a tension pneumothorax, which increases intrathoracic pressure in the thorax, causing tracheal deviation and indicating mediastinal shift
A nurse suspects a patient has a chest wall injury and wants to collect more data about thoracic expansion. Which is the appropriate technique to use?
Place both thumbs on either side of the patient's T9 to T10 spinal processes, extend fingers laterally, ask the patient to take a deep breath, and observe lateral movement of the thumbs. Option B is the correct technique to assess thoracic expansion. The
A nurse is assessing for vocal (tactile) fremitus on a patient with pulmonary edema. Which is the appropriate technique to use?
Place the palms of the hands on the right and left thoraces, ask the patient to say "99," and feel for vibrations. the correct technique for vocal fremitus
A patient is suspected of having a lung consolidation. A nurse uses the three techniques for assessing vocal resonance in this patient. What is the expected finding among the three procedures that will help eliminate consolidation as a problem?
The nurse documents hearing muffled sounds when the patient says "1-2-3." Muffled sounds of "1-2-3," "e-e-e," or "99" are heard when no consolidation is found. Clear sounds are heard when a consolidation is present.
Which patient should the nurse assess first?
The patient whose respiratory rate is 26 breaths/min and whose trachea deviates to the right. Option A is a description of a left tension pneumothorax. The key manifestation is deviation of the trachea from midline, which indicates high intrathoracic pressure from the left that is pushing the mediastinum out of alignment. The respiratory rate indicates tachypnea
A nurse is assessing the respiratory system of a healthy adult. Which findings does this nurse expect to find? (Select all that apply.)
Thoracic expansion that is symmetric bilaterally,Breath sounds clear with vesicular breath sounds heard over most lung fields,Anteroposterior diameter of the chest about a 1:2 ratio of anteroposterior to lateral diameter,Symmetric thorax with ribs sloping downward at about 45 degrees relative to the spine Options A, D, E, and F are expected findings from a lung and respiratory assessment of a healthy adult.
A nurse had previously heard crackles over both lungs of a patient. As the patient improves, what lung sounds does the nurse expect to hear in the patient's lungs?
Vesicular breath sounds heard in peripheral lung fields Vesicular breath sounds heard in peripheral lung fields are an expected finding for healthy lungs
The nurse is comparing pitch and duration of the various types of a patient's breath sounds and recognizes which one of these as an expected finding?
b. Bronchovesicular sounds have a moderate pitch and 1:1 expiratory-versus-inspiratory ratio. Bronchovesicular sounds having a moderate pitch and 1:1 expiratory-versus-inspiratory ratio is a normal finding
During a history, a nurse notices a patient is short of breath, is using pursed-lip breathing, and maintains a tripod position. Based on these data, what abnormal finding should the nurse expect to find during the examination?
d. An increased anteroposterior diameter An increased anteroposterior diameter is consistent with emphysema
