Ch19: Lungs/thorax
The thoracic cavity contains which of the following organs? Select all that apply. Pancreas Most of the esophagus Stomach Lungs Heart
Most of the esophagus Lungs Heart
The apex of each lung is located at the area slightly above the clavicle. left oblique fissure. level of the sixth rib. level of the diaphragm.
area slightly above the clavicle.
A client presents to the health care clinic and reports a recent onset of a persistent cough. The client denies any shortness of breath, change in activity level, or other findings of an acute upper respiratory tract illness. What question by the nurse is most appropriate to further assess the cause for the cough? "Are you taking any medications on a regular basis?" "Have you changed your diet within the past few weeks?" "Do you feel that you are under a great deal of stress?' "How much do you exercise during the week?"
"Are you taking any medications on a regular basis?" A persistent cough without any other respiratory symptoms could be related to new medications, especially beta blockers or angiotensin converting enzyme (ACE) inhibitors, which are prescribed for hypertension. A change in diet and exercise are healthy behaviors that would not cause a persistent cough. Stress often causes shortness of breath.
Adventitious sounds related to atelectasis and pulmonary edema are first evident when auscultating what area of the respiratory system? Trachea Bronchi Bases Apices
Bases
A client with lobar pneumonia would have muffled and indistinct spoken voice sounds. False True
False
The nurse percusses the lungs of a client with pneumonia. What percussion note would the nurse expect to document? hyperresonance flatness dullness tympany
dullness
The nurse auscultates very loud, high-pitched lung sounds that are equal in length over a client's anterior chest. Which area did the nurse most likely hear these sounds? trachea manubrium between the scapula bilateral lower lobes
trachea Tracheal sounds are very loud and harsh with inspiratory and expiratory sounds equal in length, over the trachea in the neck. Bronchial sounds are louder and higher in pitch and are heard over the manubrium. Bronchovesicular sounds are heard between the scapula. Vesicular sounds are heard over most of the lung fields.
An adult client visits the clinic and tells the nurse that he has been "spitting up rust-colored sputum." The nurse should refer the client to the physician for possible bronchitis. tuberculosis. pulmonary edema. asthma.
tuberculosis.
A person with a barrel chest has a problem doing what? Expelling excess oxygen Coughing Breathing at a normal respiratory rate Taking a deep breath
Taking a deep breath
Under normal circumstances, the strongest stimulus to breathe is hypoxemia. hypocapnia. pH changes. hypercapnia.
hypercapnia
A nurse is receiving report from the night shift about four clients. Which client would the nurse see first? A 64-year-old man with COPD who is short of breath and has a respiratory rate of 32 breaths/min A 29-year-old woman with a history of drug abuse and a heart rate of 124 beats/min A 23-year-old woman who had a mountain biking accident in which she suffered a neck fracture and now has numbness and tingling in her right arm A 57-year-old woman who had surgery yesterday for a small bowel obstruction with possible wound dehiscence
A 64-year-old man with COPD who is short of breath and has a respiratory rate of 32 breaths/min Decreased level of consciousness, respiratory rate above 30 breaths/min, cyanosis, retractions, and use of accessory muscles may indicate hypoxia (a medical emergency). The only scenario in line with these criteria is the man with COPD.
Dyspnea, an uncomfortable awareness of breathing that is inappropriate to the level of exertion, is what? Painful breathing Audible breathing Air hunger Prolonged inspiration
Air hunger
A hospitalized client experiences respiratory distress. The nurse should include which most appropriate client outcome in the plan of care? Client maintains safety; no falls Airway patent, breathing quiet, denies dyspnea Pain level stabilized at client goal Gas exchange with oxygen saturation greater than 85%
Airway patent, breathing quiet, denies dyspnea
While inspecting the thorax, the nurse views it from posterior and lateral positions to assess which of the following? Position of the trachea Inflammation of the costochondral junction Curvature of the cervical spine Anteroposterior to lateral diameter
Anteroposterior to lateral diameter
The nurse is auscultating a client's breath sounds. What should the nurse do first after hearing an unusual sound? Ask the client to cough Compare the sound with the other side Listen again with the bell of the stethoscope Change the client's position
Ask the client to cough
A nurse hears adventitious lung sounds while auscultating a client's lung fields. What action should the nurse take? Notify the health care provider. Request a STAT chest x-ray. Ask the client to cough. Document the findings as normal.
Ask the client to cough.
A 21-year-old college senior presents to the clinic reporting shortness of breath and a nonproductive nocturnal cough. She states she used to feel this way only with extreme exercise, but lately she has felt this way continuously. She denies any other upper respiratory, gastrointestinal, and urinary symptoms and says she has no chest pain. Her past medical history is significant only for seasonal allergies, for which she takes a nasal steroid spray; she takes no other medications. She has had no surgeries. Her mother has allergies and eczema; her father has high blood pressure. She is an only child. She denies smoking and illegal drug use but drinks three to four alcoholic beverages per weekend. She is a junior in finance at a local university and has recently started a job as a bartender in town. On examination she is in no acute distress. Temperature is 98.6, blood pressure is 120/80, pulse is 80, and respirations are 20. Head, eyes, ears, nose, and throat examinations are essentially normal. Inspection of her anterior and posterior chest shows no abnormalities. On auscultation of her chest, there is decreased air movement and a high-pitched whistling on expiration in all lobes. Percussion reveals resonant lungs. Which disorder of the thorax or lung does this presentation best describe? Pneumonia Asthma Spontaneous pneumothorax Chronic obstructive pulmonary disease (COPD)
Asthma Asthma causes shortness of breath and a nocturnal cough. It is often associated with a history of allergies and can be exacerbated by exercise or irritants such as smoke in a bar. On auscultation there can be normal to decreased air movement. Wheezing is heard on expiration and sometimes inspiration. The duration of wheezing in expiration usually correlates with the severity of illness, so it is important to document this length (e.g., wheezes heard halfway through exhalation). In severe asthma, wheezes may not be heard because of the lack of air movement. Paradoxically, these clients may have more wheezes after treatment, which actually indicates an improvement in condition. Peak flow measurements help to discern this.
During a physical assessment, the nurse identifies unequal chest expansion. The nurse knows this could be due to what? Select all that apply. Atelectasis Trauma Emphysema Pneumothorax Pneumonia
Atelectasis Trauma Pneumothorax Pneumonia Decreased chest excursion is seen with emphysema. Asymmetrical chest movements may be due to pneumonia, pneumothorax, trauma or atelectasis.
The nurse is preparing to percuss a client's anterior chest area. Which approach will the nurse use for this assessment? Select all that apply. Avoid surface contact by any other part of the hand. Press the nondominant hand's distal interphalangeal joint firmly on the surface to be percussed. Hyperextend the middle finger of the nondominant hand. Strike the pleximeter finger with the dominant middle finger with a tight and deliberate wrist motion. Avoid having the thumb and second, fourth, and fifth fingers touch the chest.
Avoid surface contact by any other part of the hand. Press the nondominant hand's distal interphalangeal joint firmly on the surface to be percussed. Hyperextend the middle finger of the nondominant hand. Avoid having the thumb and second, fourth, and fifth fingers touch the chest. The nurse should hyperextend the middle finger of the nondominant hand, press the nondominant hand's distal interphalangeal joint firmly on the surface to be percussed, avoid surface contact by any other part of the hand, and avoid having the thumb and second, fourth, and fifth fingers touch the chest. The nurse should strike the pleximeter finger with the dominant middle finger with a quick, sharp but relaxed wrist motion, not a tight and deliberate wrist motion.
A nurse is interviewing a client who complains of dyspnea of sudden onset. Based on this finding, the nurse should suspect which of the following causes? Bacterial infection Sleep apnea Lung cancer Emphysema
Bacterial infection Gradual onset of dyspnea is usually indicative of lung changes such as emphysema, whereas sudden onset is associated with viral or bacterial infections. Lung cancer and sleep apnea are chronic conditions, which would be more likely to result in a gradual onset of dyspnea.
Which of the following statements relating to assessment of the lungs and thorax is most accurate? Loud and very loud percussion notes denote pathological findings. Hemoptysis is more common in children and adolescents than in older clients. Moderate to severe chest pain is associated with a cardiac etiology, while mild to moderate chest pain is most often respiratory in origin. Bronchitis is characterized by excess mucus production and chronic cough.
Bronchitis is characterized by excess mucus production and chronic cough. Bronchitis is marked by a chronic, productive cough that results from excess mucus production. Hemoptysis is uncommon in younger clients. It would be simplistic to differentiate cardiac from respiratory chest pain based on severity alone. Similarly, it is inaccurate to characterize all loud percussion sounds as pathological.
What type of respiratory pattern would the nurse consider normal in a client with severe heart failure? Bradypnea Cheyne-Stokes Biot's Kussmaul
Cheyne-Stokes Cheyne-Stokes respirations, regular respiratory pattern alternating with periods of deep, rapid breathing followed by periods of apnea, may result from severe heart failure. Biot's respirations (irregular pattern of varied depth and rate followed by periods of apnea) may be seen with severe brain damage or meningitis. Bradypnea is a rate less than 10/min and can be associated with medication-induced depression of the respiratory center, diabetic coma, or neurologic damage. Kussmaul respirations are associated with diabetic ketoacidosis.
What type of respiratory pattern would the nurse consider normal in a client with severe heart failure? Cheyne-Stokes Kussmaul Biot's Bradypnea
Cheyne-Stokes Cheyne-Stokes respirations, regular respiratory pattern alternating with periods of deep, rapid breathing followed by periods of apnea, may result from severe heart failure. Biot's respirations (irregular pattern of varied depth and rate followed by periods of apnea) may be seen with severe brain damage or meningitis. Bradypnea is a rate less than 10/min and can be associated with medication-induced depression of the respiratory center, diabetic coma, or neurologic damage. Kussmaul respirations are associated with diabetic ketoacidosis.
A client experiences increasing difficulty taking in a deep breath. For which health problem should the nurse focus when assessing this client? Anxiety Chronic obstructive lung disease Pulmonary embolism Congestive heart failure
Chronic obstructive lung disease The client with COPD may describe the dyspnea as not being able to "breathe or take a deep breath." Although dyspnea is associated with anxiety, pulmonary embolism, and congestive heart failure, the shortness of breath is not described as the inability to take in a deep breath.
Upon inspection of a client's chest, a nurse observes an increase in the ratio of anteroposterior to transverse diameter. The nurse recognizes this as a finding in which disease process? Chronic obstructive pulmonary disease Pneumothorax Carcinoma of the lungs Tuberculosis
Chronic obstructive pulmonary disease
A 62-year-old construction worker presents to the clinic reporting almost a chronic cough and occasional shortness of breath that have lasted for almost 1 year. Although symptoms have occasionally worsened with a cold, they have stayed about the same. The cough has occasional mucus drainage but never any blood. He denies any chest pain. He has had no weight gain, weight loss, fever, or night sweats. His past medical history is significant for high blood pressure and arthritis. He has smoked two packs a day for the past 45 years. He drinks occasionally but denies any illegal drug use. He is married with two children. He denies any foreign travel. His father died of a heart attack and his mother died of Alzheimer's disease. Examination reveals a man looking slightly older than his stated age. His blood pressure is 130/80 and his pulse is 88. He is breathing comfortably with respirations of 12. His head, eyes, ears, nose, and throat examinations are unremarkable. His cardiac examination is normal. On examination of his chest, the diameter seems enlarged. Breath sounds are decreased throughout all lobes. Rhonchi are heard over all lung fields. There is no area of dullness and no increased or decreased fremitus. What thorax or lung disorder is most likely causing his symptoms? Asthma Pneumonia Chronic obstructive pulmonary disease (COPD) Spontaneous pneumothorax
Chronic obstructive pulmonary disease (COPD) This disorder is insidious in onset and generally affects the older population with a smoking history. The diameter of the chest is often enlarged like a barrel. Percussing the chest elicits hyperresonance; during auscultation there is often distant breath sounds. Coarse breath sounds of rhonchi are also often heard. It is important to quantify this client's exercise capacity because it may affect his employment and also allows examiners to follow the progression of his disease. Clinicians must offer smoking cessation as an option.
During the lung assessment for a client with pneumonia, the nurse auscultates low-pitched, bubbling, moist sounds that persist from early inspiration to early expiration. How should the nurse document these sounds? Coarse crackles Sonorous wheezes Sibilant wheezes Pleural friction rubs
Coarse crackles
When auscultating a client's lungs, the nurse hears a sound like Velcro being pulled apart over the client's right middle lobe. How should the nurse document this finding? Sibilant wheeze Coarse crackles Fine crackles Sonorous wheeze
Coarse crackles Coarse crackles are low-pitched bubbling moist sounds that are described as separating Velcro. Fine crackles are high-pitched, short, popping sounds heard during inspiration and not cleared with coughing. Sibilant wheezes are high-pitched musical sounds. Sonorous wheezes are low-pitched snoring or moaning sounds.
What replaces resonance when fluid or solid tissue replaces air-containing lung or occupies the pleural space? Chief complaint Tympany Hyperresonance Dullness
Dullness Dullness replaces resonance when fluid or solid tissue replaces air-containing lung or occupies the pleural space.
The client has been admitted through the emergency department with chronic bronchitis, has elevated CO2 levels, and has been placed on O2. What priority assessment would the nurse include? Assess for signs of nonproductive cough. Assess the characteristics of sputum. Evaluate changes in respiratory pattern and rate. Review blood work including RBC and WBC.
Evaluate changes in respiratory pattern and rate.
A client comes to the clinic and states, "I have a bad cold and am having trouble breathing." The nurse checks the client's breath sounds and hears bilateral fine crackles at the base. Of what is this finding indicative? Fluid in the alveoli Fluid in the bronchus No fluid present Fluid in the bronchioles
Fluid in the alveoli When fluid fills the alveoli, fine crackles may be audible on auscultation. Excessive fluid in the alveoli may lead to airway collapse and decreased breath sounds. Fine crackles are not indicative of fluid in the bronchioles or bronchus or the absence of fluid in the lungs.
Which characteristic feature of the sternum should the nurse observe in a client with the diagnosis of pectus carinatum? Forward protrusion Sunken along with the adjacent cartilages Horizontal sternum with increased intercostal angle Midline and straight
Forward protrusion
What would the nurse expect to hear when auscultating the lungs of a client diagnosed with pleuritis? Sibilant wheeze Decreased breath sounds Friction rub Stridor
Friction rub In pleuritis, inflamed pleural surfaces lose their normal lubrication and rub together during breathing. Reduced volume of pleural fluid increases the transmission of lung sounds and leads to a possible friction rub. Decreased breath sounds may indicate an obstruction due to little air moving in and out. Sibilant wheezes are often heard with bronchitis; stridor occurs with severe broncholaryngo spasms, such as croup. Stridor is associated with a loud, high-pitched crowing that is characteristic of epiglottis or other conditions that partially obstruct the upper airway.
The nurse is reviewing the client's health history and notes he has pectus excavatum. The nurse would assess the client for what? Funnel chest Pectoriloquy Intercostal bulging Pigeon chest
Funnel chest Pectus excavatum or funnel chest occurs when the sternum and adjacent cartilages are significantly sunken inward or dented. Pigeon chest or pectus carinatum occurs when the sternum protrudes backward. Intercostal bulging is noted with trapped air. Whispering pectoriloquy is identified when sounds are louder and clearer than the whispered sounds.
A grandmother brings her 13-year-old grandson for evaluation. She noticed last week when he took off his shirt that his breastbone seemed collapsed. He seems embarrassed and says that it has been that way for awhile. He states he has no symptoms from it and that he just tries not to take off his shirt in front of anyone. He denies any shortness of breath, chest pain, or lightheadedness on exertion. His past medical history is unremarkable. He is in sixth grade and just moved in with his grandmother after his father was transferred for a work contract. His mother died several years ago in a car accident. He states that he does not smoke and has never touched alcohol. Examination shows a teenage boy appearing his stated age. Visual examination of his chest reveals that the lower portion of the sternum is depressed. Auscultation of the lungs and heart is unremarkable. What disorder of the thorax best describes these findings? Barrel chest Thoracic kyphoscoliosis Pigeon chest (pectus carinatum) Funnel chest (pectus excavatum)
Funnel chest (pectus excavatum)
What should be the nurse's initial intervention when adventitious sounds are heard during auscultation of a client's lungs? Refer the client for further medical evaluation. Auscultate for egophony. Have the client cough and then listen again. Perform bronchophony.
Have the client cough and then listen again. If abnormalities are noted during lung auscultation, the nurse should have the client cough and then listen again, noting any change. Coughing may clear the lungs. If the sounds are still present after coughing, then the nurse would refer the client for further evaluation. Auscultating voice sounds (egophony and bronchophony) would be done as part of any assessment of the thorax.
During a health history, a client tells the nurse that "I can't breathe well at night when I'm lying down". The client also reports an interrupted sleep pattern caused by waking up with trouble breathing and a nagging cough. Considering the client's reports, what medical condition should the nurse's assessment be focused on? Bronchitis Tuberculosis-related cough Pneumonia-related dyspnea Heart failure induced orthopnea
Heart failure induced orthopnea Difficulty breathing when lying supine (orthopnea) may be associated with heart failure. Paroxysmal nocturnal dyspnea (severe dyspnea that awakes a person from sleep) also is associated with heart failure. There is no indication that the client might have pneumonia, tuberculosis, or bronchitis. These conditions would most likely involve a client's report of cough with or without mucus production.
A client presents to the health care facility with a 2-week history of persistent dry, hacky cough, chest tightness, and shortness of breath with activity. The client admits to a 1-pack-per-day history of cigarette smoking for 20 years. The nurse observes a respiratory rate of 16 breaths per minute, easy and regular. Which nursing diagnosis should the nurse confirm based on this assessment data? Risk for Imbalanced Nutrition Impaired Gas Exchange Ineffective Airway Clearance Disturbed Sleep Pattern
Impaired Gas Exchange Impaired Gas Exchange related to chronic lung tissue damage secondary to chronic smoking can be confirmed because of the major criteria of long-standing smoking, shortness of breath, and activity intolerance. The client's cough is dry and hacky, which does not meet the criteria for Ineffective Airway Clearance. There is no data to support the client experiencing a disturbance in sleep or problems with nutrition.
A client presents to the health care facility with sudden onset of shortness of breath, inability to lie flat, and a deep, wet cough. A nurse observes a respiratory rate of 18 breaths per minute, use of accessory muscles to breathe, and inability to cough up secretions. Which nursing diagnosis can be confirmed with this data? Ineffective Airway Clearance Risk for Respiratory Infection Ineffective Breathing Pattern Impaired Gas Exchange
Ineffective Airway Clearance
A nurse auscultates a client's lungs and hears fine crackles. What is an appropriate action by the nurse? Listen again with the bell of the stethoscope Assess for the use of accessory muscles Have the client breathe through the mouth Instruct the client to cough forcefully
Instruct the client to cough forcefully
The nurse auscultates the base of the lungs to assess for what reason? It best reflects the health of the lungs. It indicates early infection. It is where fluid occurs with pulmonary edema.
It is where fluid occurs with pulmonary edema. Auscultation of the bases is important because it is where fluid occurs with pulmonary edema and the location for fluid accumulation with a pleural effusion. It does not indicate infection or health of the lungs.
Which characteristic of a cough should alert the nurse to assess the client for other findings of sinusitis? Onset upon awakening Nighttime when lying down Intermittent but worse in evening Persistent all day
Nighttime when lying down A cough that occurs when lying down at night is due to sinusitis or postnasal drip. Continuous coughs are usually associated with acute infections; whereas those occurring only early in the morning are often associated with chronic bronchial inflammation or smoking. Coughs late in the evening may be the result of exposure to an irritant during the day.
A nurse observes a client sitting in the tripod position. What is an appropriate action by the nurse in response to this observation? Auscultate for the presence of crackles Observe for the use of accessory muscles Palpate for tactile fremitus Percuss to determine diaphragmatic excursion
Observe for the use of accessory muscles The tripod position is often assumed by the client with chronic obstructive pulmonary disease (COPD) in order to help elevate the diaphragm during inspiration. This is often accompanied by the use of accessory muscles of the neck. Crackles are present in pneumonia or fluid in the lungs. Tactile fremitus helps to assess for the presence of a consolidation such as pleural effusion or pneumonia. Diaphragmatic excursion assesses the movement of the diaphragm.
An elderly client reports a feeling of dyspnea with normal activities of daily living. What is an appropriate action by the nurse? Observe the client's respiratory rate and pattern Ask the client how long they have to rest between activities Report this to the health care provider immediately Assess for symmetry of chest expansion
Observe the client's respiratory rate and pattern It is normal for elderly clients to feel short of breath or dyspneic with activities of daily living due to age related changes of loss of elasticity, fewer functional capillaries, and loss of lung resiliency. Observing chest expansion would be appropriate assessment for a client with a pneumothorax. This finding does not need to be reported to the health care provider unless accompanied by other findings of inadequate oxygenation. Asking the client how long they need to rest between activities will not provide the nurse any objective information to differentiate the problem.
When auscultating the lungs, the nurse listens over symmetrical lung fields for which of the following? One quiet full inspiration through pursed lips Two full breaths every 10 seconds through the nose One deep inspiration and expiration through the open mouth Two full breaths in through the mouth and out through the nose
One deep inspiration and expiration through the open mouth Lung auscultation is performed for one full breath over symmetrical lung fields. The client should be encouraged to breathe deeply through an open mouth.
A client who just underwent hip replacement surgery reports pain at a 10 on a scale of 0 to 10 and receives 4 mg of morphine. A nurse on the orthopedic unit enters the client's room and finds that the client has a respiratory rate of 7 breaths/min. The client is groggy and hard to arouse. What could be contributing to the client's findings? Opiates, which may cause hyperventilation Nothing, this is normal following surgery Anesthesia, from surgery that morning Opiates, which may cause hypoventilation
Opiates, which may cause hypoventilation
While performing an assessment of a client who sustained a chest injury, which physical examination technique should the nurse use to elicit crepitus? Percussion Auscultation Palpation Inspection
Palpation
During a comprehensive physical assessment at a home visit, a client reports chest discomfort. What is the first action of the nurse? Call for an ambulance. Perform a focused assessment. Continue the comprehensive assessment. Notify the health care provider immediately.
Perform a focused assessment. The nurse should immediately perform a focused assessment on the client to determine the origin of the pain, such as using COLDSPA (characteristic, onset, location, duration, severity, palliative, associated). The nurse should not contact the health care provider until the focused assessment has been completed. The nurse should not continue with the comprehensive assessment but rather perform a focused assessment of the chest pain. There is not enough information for the nurse to call an ambulance.
What color of sputum would support the diagnosis of heart failure? Yellow White Pink Rust
Pink Pink sputum is associated with heart failure. White sputum typically is seen with the common cold. Yellow sputum suggests a bacterial infection. Rust-colored sputum is associated with tuberculosis or pneumococcal pneumonia.
Which action by a nurse demonstrates proper technique for assessment of chest expansion? Use the ball of both hands to feel for vibrations in a symmetrical pattern across the posterior chest Place both hands on the posterior chest at T9, press thumbs together, and then ask client to take a deep breath Place the stethoscope on the posterior chest wall, ask the client to take a deep breath, and observe chest rise and fall Beginning at the scapular line, percuss the intercostal spaces along both sides of the posterior chest
Place both hands on the posterior chest at T9, press thumbs together, and then ask client to take a deep breath
The nurse obtains a flat sound when percussing the right lower lobe of a client. What does this assessment finding indicate to the nurse? Healthy lung tissue Emphysema Pleural effusion Gastric air bubble
Pleural effusion When a flat sound is percussed over lung tissue, this is an indication of a pleural effusion. Resonance is the percussion sound of healthy lung tissue. The sound of a gastric air bubble is tympany. Hyperresonance is the percussion sound associated with emphysema.
A client reports sharp and stabbing chest pain that worsens with deep breathing and coughing. A cardiac cause to this pain is ruled out. The description of the pain is consistent with what respiratory condition? Pleurisy Pneumonia Rales Asthma
Pleurisy Pleurisy can follow inflammation of the parietal pleura. Patients usually describe such pain as sharp or stabbing, worsening with deep breathing or coughing. Pneumonia does not always cause pain on respiration nor does asthma. Rales are an adventitious breath sound, not a respiratory condition.
A 47-year-old receptionist comes to the office with fever, shortness of breath, and a productive cough with golden sputum. She says she had a cold last week and her symptoms have only worsened despite using over-the-counter cold remedies. She denies any weight gain, weight loss, or cardiac or gastrointestinal symptoms. Her past medical history includes type 2 diabetes for 5 years and high cholesterol level. She takes an oral medication for both diseases. She has had no surgeries. She denies tobacco, alcohol, or drug use. Her mother has diabetes and high blood pressure. Her father passed away from colon cancer. Examination reveals a middle-aged woman appearing her stated age. She looks ill and her temperature is elevated at 101 degrees Fahrenheit. Her blood pressure and pulse are unremarkable. Her head, eyes, ears, nose, and throat examination are unremarkable except for edema of the nasal turbinates. On auscultation she has decreased air movement and coarse crackles are heard over the left lower lobe. There is dullness on percussion, increased fremitus during palpation, and egophony and whispered pectoriloquy on auscultation. What disorder of the thorax or lung best describes her symptoms? Pneumonia Spontaneous pneumothorax Asthma Chronic obstructive pulmonary disease (COPD)
Pneumonia Pneumonia is usually associated with dyspnea, cough, and fever. On auscultation there can be coarse or fine crackles heard over the affected lobe. Percussion over the affected area is dull, and there is often an increase in fremitus. Egophony and pectoriloquy are heard because of increased sound transmission of high-pitched components of sounds. The multiple air-filled chambers of the alveoli usually filter out these higher frequencies.
A client is brought to the emergency department by ambulance after being involved in a motor vehicle accident. The nurse finds that he has decreased breath sounds over the left lung fields. What might the nurse suspect is the cause? Muscular weakness Atelectasis Asthma Pneumothorax
Pneumothorax
The client tells the nurse that he has been coughing up pink, frothy sputum. The nurse notifies the health care provider because the client may have what condition? Tuberculosis Infection Pulmonary edema Atelectasis
Pulmonary edema Pink, frothy sputum may indicate pulmonary edema. Tuberculosis sputum may be a rusty color and green sputum may indicate an infection. The client with atelectasis may not be coughing any sputum up.
When percussing the anterior chest for tone, a nurse should anticipate what tone over the majority of the lung fields? Dullness Hyperresonance Resonance Tympany
Resonance
When percussing the posterior lung fields, which of the following findings is expected? Resonance over all lung fields Tympany over 11th interspace, right scapular line Hyperresonance over apices Dullness over the lung bases
Resonance over all lung fields All lung tissue is expected to be resonant on percussion. Hyperresonance and tympany suggest a hyperinflated lung or pneumothorax. Dullness is expected in structures below the level of the diaphragm, but dullness in the bases of the lungs themselves would be considered pathological.
A nurse is assessing a client with acute asthma. Which adventitious breath sound should the nurse expect to hear in this client? Fine crackles occurring late in inspiration Sonorous wheezes heard primarily during expiration but may be heard throughout the respiratory cycle Sibilant wheezes heard primarily during expiration but may also be heard on inspiration Course crackles occurring from early inspiration to early expiration
Sibilant wheezes heard primarily during expiration but may also be heard on inspiration Sibilant wheezes are often heard in cases of acute asthma or chronic emphysema. Fine crackles occurring late in inspiration are associated with restrictive diseases such as pneumonia and congestive heart failure. Course crackles that persist from early inspiration to early expiration may indicate pneumonia, pulmonary edema, or pulmonary fibrosis. Sonorous wheezes are often heard in cases of bronchitis or single obstructions and snoring before an episode of sleep apnea.
Which of the following occurs in respiratory distress? Client torso leans posteriorly. The client speaks in sentences of 10-20 words. Neck muscles are relaxed. Skin between the ribs moves inward with inspiration.
Skin between the ribs moves inward with inspiration.
A high-pitched crowing sound from the upper airway results from tracheal or laryngeal spasm and is called what? Stridor Rales Crackles Wheezes
Stridor Stridor, a high-pitched crowing sound from the upper airway, results from tracheal or laryngeal spasm. In severe laryngospasm, the larynx may completely close off. This life-threatening emergency requires immediate medical assistance. Crackles, wheezes, and rales are adventitious breath sounds heard upon auscultation of the lungs.
In palpating the chest of a client, a nurse feels a U-shaped indentation on the superior border of the manubrium. The nurse recognizes this landmark as which of the following? Acromion of the scapula Xiphoid process Suprasternal notch Sternal angle
Suprasternal notch
When assessing posteriorly, where would the trachea bifurcate into its mainstem bronchi? Sternal angle Midaxillary line Suprasternal notch T4 spinous process
T4 spinous process The trachea bifurcates into its mainstem bronchi at the levels of the sternal angle anteriorly and the T4 spinous process posteriorly.
Which observation confirms to the nurse that the client is experiencing a normal inspiration? The diaphragm is seen relaxing. Air can be heard moving out of the tracheobronchial tree. The thoracic cavity enlarges. The abdominal wall is pushed inward.
The thoracic cavity enlarges.
The nurse working in a hospital assesses the respiratory status of a 64-year-old male client with a history of chronic obstructive pulmonary disease (COPD). Complete the following sentences by choosing from the lists of options. Upon inspection, the client is in the tripod position, has a barrel chest and the nails are clubbed, Crackles are heard on ausculation.
The tripod position facilitates lung expansion for a client with chronic obstructive pulmonary disease (COPD). The client in the tripod position is seated, leaning forward with the arms supported on the knees or over the bed table. (The supine and prone positions would be uncomfortable and restrict oxygenation in the client with COPD.) A barrel chest is associated with COPD. The AP-to-transverse ratio approximates 1:1, giving the chest a round appearance. Also, with COPD, the expanded ribs slope more horizontally. A funnel chest (sunken sternum and rib cartilages) and pigeon chest (protruding sternum) are considered congenital malformations and are not associated with COPD. Fingernails at an angle of 180 degrees or more is called clubbing of the fingers. This finding is associated with long-term (chronic) hypoxia, which occurs in COPD. Normal nails are pink and smooth. Crackles are high-pitched, short, popping sounds heard on inspiration and are not cleared with coughing. The sounds are not continuous and are associated with chronic lung diseases such as COPD. Wheezes are high-pitched musical sounds heard on inspiration or expiration and are associated with asthma. Continuous sounds are low-pitched, dry, grating sounds that occur during both inspiration and expiration. Continuous sounds are associated with a pleural friction rub or pleuritis.
Which characteristic associated with respiratory effort should be considered when planning care for a client diagnosed with a brainstem injury? The client will respond negatively to increased stimuli. There is an increased level of carbon dioxide in the blood. There is loss of involuntary respiratory control. The client's oxygen levels in the blood will be increased.
There is loss of involuntary respiratory control. The brainstem contains the medulla and the pons, which control involuntary respiratory effort. The negative response to stimuli is unrelated to the client's respiratory effort. The client's breathing patterns will change according to cellular demands. The levels of carbon dioxide and oxygen in the blood also will vary based on the client's respiratory efforts as well as interventions used to sustain these efforts.
Which finding during an assessment of a client should alert the nurse to the presence of a persistent atelectasis? Unequal expansion of the chest Retraction of intercostal spaces The presence of crepitus on palpation A depressed sternum and cartilages
Unequal expansion of the chest
Which finding during an assessment of a client should alert the nurse to the presence of a persistent atelectasis? Unequal expansion of the chest The presence of crepitus on palpation Retraction of intercostal spaces A depressed sternum and cartilages
Unequal expansion of the chest Unequal expansion of the chest indicates atelectasis or lung collapse. The inhaled air is unable to inflate the diseased lung; therefore, there is an unequal expansion of the chest. Crepitus on palpation can be found in clients with an open thoracic injury or with a tracheostomy. Sunken sternum and adjacent cartilages are seen in funnel chest. Retraction of intercostal spaces occurs in labored breathing.
The nurse is preparing to auscultate the posterior thorax of an adult female client. The nurse should ask the client to breathe normally through her nose. ask the client to breathe deeply through her mouth. auscultate from the base of the lungs to the apices. place the bell of the stethoscope firmly on the posterior chest wall.
ask the client to breathe deeply through her mouth. To best assess lung sounds, you will need to hear the sounds as directly as possible. Ask the client to breathe deeply through the mouth for each area of auscultation. -> the nose/nasal sound obscures lung sounds
The nurse assesses an adult client and observes that the client's breathing pattern is very labored and noisy, with occasional coughing. The nurse should refer the client to a physician for possible chronic bronchitis. atelectasis. renal failure. congestive heart failure.
chronic bronchitis. Labored and noisy breathing is often seen with severe asthma or chronic bronchitis.
When auscultating a client's lungs, the nurse hears a loud popping sound that clears when the client coughs. What sound is this client most likely demonstrating? rhonchi fine crackles wheezes coarse crackles
coarse crackles Coarse crackles change or disappear with coughing. Rhonchi are a variation of wheezes but are lower in pitch. They may also disappear with coughing. Wheezes are continuous musical sounds. Fine crackles are soft, high-pitched and change according to body position.
The nurse has assessed the respiratory pattern of an adult client. The nurse determines that the client is exhibiting Kussmaul respirations with hyperventilation. The nurse should contact the client's physician because this type of respiratory pattern usually indicates drug overdose. congestive heart failure. central nervous system injury. diabetic ketoacidosis.
diabetic ketoacidosis.
A client comes to the clinic reporting difficulty breathing for the past few weeks after being prescribed a new medication, a beta-blocker, for hypertension. The client's past medical history includes hypertension and smoking (2 packs/day × 20 years). The nurse assesses the client and finds the following: slight inspiratory and expiratory wheezing heard in upper lung fields, no mucus or fever, and oxygen saturations are within normal limits (95% on room air). The nurse suspects that the client may be experiencing which of the following conditions? episodic dyspnea drug-induced asthma bacterial pneumonia chronic obstructive pulmonary disease (COPD)
drug-induced asthma Some medications, such as beta-blockers and ACE inhibitors, can cause difficulty breathing (constriction) and coughing. Because the client started experiencing the symptoms after the new medication was prescribed, the nurse should consider the wheezing (constriction) and difficulty breathing as connected to the medication, which is known to cause bronchoconstriction in some people. Although this is dyspnea, that is not the best option. Because the client does not have any of the symptoms of bacterial pneumonia—for example, fever, productive cough and no crackles or rhonchi were heard in the lung fields—this is not the correct answer. Although wheezing may occur in clients who have COPD, the information provided indicates that the wheezing is drug-induced.
After percussing a client's lung fields the nurse suspects a client has a chronic lung disease. What sound did the nurse hear to make this clinical determination? flat dull resonance hyperresonance
hyperresonance
A nurse is palpating the sternum of a client. If the client is healthy, which of the following would characterize his costal angle? less than 90 degrees 110 degrees 100 degrees 45 degrees
less than 90 degrees The right and left costal margins meeting at the level of the xiphoid process form an angle between them. This angle, commonly referred to as the costal angle, is an important landmark for assessment. It is normally less than 90 degrees but may be increased in instances of long-standing hyperinflation of the lungs, as in emphysema.
A client is coughing copious amounts of purulent mucous. What disease condition is related to this finding? lung abscess cystic fibrosis lung cancer pneumococcal pneumonia
lung abscess Large volumes of purulent sputum may occur in a lung abscess. Bloody sputum is associated with lung cancer. Tenacious sputum is associated with cystic fibrosis. Rust-colored sputum is associated with tuberculosis or pneumococcal pneumonia.
The clavicles extend from the acromion of the scapula to the part of the sternum termed the angle. body. manubrium. xiphoid process.
manubrium
Which pleural membrane lines the chest cavity? thoracic pleura visceral pleura parietal pleura pulmonary pleura
parietal pleura
The nurse assesses an adult client's thoracic area and observes a markedly sunken sternum and adjacent cartilages. The nurse should document the client's pectus excavatum. pectus thorax. pectus diaphragm. pectus carinatum.
pectus excavatum.
While assessing an adult client's lungs during the postoperative period, the nurse detects coarse crackles. The nurse should refer the client to a physician for possible pleuritis. pneumonia. asthma. bronchitis.
pneumonia Crackles occurring late in inspiration are associated with restrictive diseases such as pneumonia.
The nurse is assessing a client's thorax. Which structures should the nurse identify as articulating anteriorly with the 10th rib? the spine sternum nothing previous rib cartilages
previous rib cartilages
While assessing the thoracic area of an adult client, the nurse plans to auscultate for voice sounds. To assess bronchophony, the nurse should ask the client to repeat the letter "A." whisper the phrase "one-two-three." repeat the letter "E." repeat the phrase "ninety-nine."
repeat the phrase "ninety-nine."
The nurse is preparing to auscultate the lung sounds of a client. Which sound will the nurse expect to hear over most of the client's lungs? vesicular tracheal bronchovesicular bronchial
vesicular Vesicular breath sounds are normally heard over most of both lungs. Bronchovesicular breath sounds are normally heard in the 1st and 2nd intercostal spaces anteriorly and between the scapulae posteriorly. Bronchial breath sounds are normally heard over the manubrium but may not be heard at all. Tracheal breath sounds are normally heard over the trachea in the neck.
