Chapter 11 ~ Lungs and Respiratory

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? a. Ask the patient to cough and repeat auscultation. b. Percuss the posterior thorax for tone. c. Palpate the posterior thorax for vocal fremitus. d. Auscultate the posterior thorax for vocal sounds.

A

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.) a. Dull tones to percussion b. Increased vibration on vocal fremitus c. Fever d. Decreased diaphragmatic excursion e. A sharp, abrupt pain reported when patient breathes deeply f. Muffled sounds heard when the patient says e-e-e

A, B, C, E

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? a. Wheezes are low-pitched and have a 2.5:1 inspiratory-versus-expiratory ratio. b. Bronchovesicular sounds have a moderate pitch and 1:1 expiratory-versus-inspiratory ratio. c. Bronchial sounds are low-pitched and have a 2:1 inspiratory-versus-expiratory ratio. d. Vesicular breath sounds are high-pitched and have a 1:2 inspiratory-versus-expiratory ratio.

B

The nurse percusses a patient's chest and feels dullness. The nurse suspects which diagnosis? a. Emphysema b. Pneumonia c. Bronchiectasis d. Chronic obstructive pulmonary disease (COPD)

B

The student nurse is reviewing the pathophysiology of inspiration. The primary muscles of inspiration are the diaphragm and the __. a. pectoral muscles b.external intercostal muscles c. abdominal muscles d. scalene muscles

B

After taking a brief health history, a nurse needs to complete a focused assessment on which patient? a. A female who has a history of gout b. A female who recently moved into a college dormitory c. A male who works as a painter d. A male who plays basketball and hockey

C

Hyper secretion of mucus by goblet cells of trachea and bronchi. S/S include chronic, productive cough

Chronic bronchitis

A nurse suspects a viral infection or upper respiratory allergies when the patient describes the sputum as being what color?

Clear

Fine, high pitched popping. End of inspiration. Congestion (prolonged bed rest; pneumonia)

Crackles

A patient complains to the nurse of coughing up green phlegm and is having difficulty breathing at rest. The nurse suspects: a. a viral infection. b. tuberculosis. c. pulmonary edema. d. bacterial pneumonia.

D

Destruction of alveolar walls that cause permanent abnormal enlargement of air spaces. Signs and symptoms include underweight with barrel chest and SOB with minimal exertion

Emphysema

The RN is caring for a patient with a long hx of COPD (respiratory disease) who is experiencing an exacerbation. The RN quickly assesses the client's vital signs. What unexpected findings are likely to be present?

Hypoxia/Low SaO2 Tachypnea Tachycardia

The RN is caring for a patient with a long hx of COPD (respiratory disease) who is experiencing an exacerbation. The RN continues her assessment of the client's respiratory status by inspection. What additional unexpected findings are likely to be present?

Nasal flaring Retractions Use of accessory muscles Pursed lip breathing Barrel chest

Where does a nurse expect to hear bronchovesicular lung sounds in a healthy adult?

Near the sternal border

As the RN auscultates the client's lungs, she makes a note of five (5) characteristics of breath sounds. These are:

Pitch Intensity Duration Expected Location Abnormal Location (Quality)

AP:L diameter = 1:1; costal angle > 90°

barrel chest

increased sputum in AM

bronchitis

The RN is caring for a patient with a long hx of COPD (respiratory disease) who is experiencing an exacerbation. The RN inspects the client's integumentary system for evidence of hypoxia. What findings are likely to be noted?

clubbing cyanosis

Structures in the mediastinum

heart arch of aorta superior vena cava lower esophagus lower part of trachea

The three main structures within thorax or chest are:

mediastinum right plural cavity left plural cavity

The RN is caring for a patient with a long hx of COPD (respiratory disease) who is experiencing an exacerbation. Based on the client's behavior, the RN suspects that there is decreased perfusion to the brain. What s/s would support this?

Restlessness Anxiety Apprehension If advanced: confusion and mental status changes

white/clear sputum

cold; viral infection

A nurse hears bronchovesicular sounds in the posterior chest on either side of the spine. This finding indicates: a. a normal finding b. pneumonia c. lung cancer d.pleural effusion

A

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? a. Hold stethoscope firmly to prevent movement when placed over chest hair. b. Change the patient's position to ensure accurate sounds. c. Make sure the bell of the stethoscope is used, rather than the diaphragm. d. Ask the patient not to talk while the nurse is listening to the lungs.

A

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? a. Bronchophony reveals the patient's spoken "99" as clear and loud. b. No sounds are expected since sounds cannot be transmitted through consolidation. c. Egophony reveals indistinguishable sounds when the patient says "e-e-e." d. Whispered pectoriloquy reveals a muffled sound when the patient says "1-2-3."

A

The examiner notes a diaphragmatic excursion of 4 cm on the right side and 8 cm on the left side. What do these findings mean? a. The patient may have a pleural effusion. b. The patient may have a pneumothorax. c. Asymmetric findings are common in well-conditioned adults. d. This is a normal finding because the right lung is larger than the left lung.

A

The nurse assesses a patient who has a costal angle greater than 90 degrees. What is the most likely cause of this finding? a. Chronic obstructive pulmonary disease b. Pneumothorax c. Infant respiratory distress syndrome d. Atelectasis

A

What are the functions of the upper airways? (Select all that apply.) a. Conduct air to lower airway. b. Provide area for gas exchange. c. Prevent foreign matter from entering respiratory system. d. Warm, humidify, and filter air entering lungs. e. Provide transportation of oxygen and carbon dioxide between alveoli and cells.

A, C, D

Inflammation of the bronchial tree caused by virus or bacteria. S/S include cough, chest pain, rhonchi and crackles; wheezing heard after coughing

Acute bronchitis

A nurse is auscultating the lungs of a healthy female patient and hears crackles on inspiration. What action can the nurse take to ensure this is an accurate finding

Ask patient to cough then repeat auscultation

Hyperreactive airway disease characterized by bronchoconstriction, airway obstruction, and inflammation in response to inhalation of allergens or pollutants, infection, cold air, vigorous exercise, or emotional stress.

Asthma

A nurse examines a patient with a pleural effusion and finds decreased fremitus. What additional abnormal finding should the nurse anticipate during further examination? a. Hyperresonance over the affected area b. Absent breath sounds in the affected area c. An increase in the anteroposterior to lateral ratio d. Increased vocal fremitus over the affected area

B

A nurse hears inspiratory and expiratory wheezes bilaterally. What is the meaning of this finding? a. Consolidation in alveoli b. Narrowed airways c. Sputum in the bronchi d. Fluid in the alveoli

B

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? a. Place the palmar side of each hand against the lateral thorax at the level of the waist, ask the patient to take a deep breath, and observe lateral movement of the hands. b. 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. c. Place both thumbs on either side of the patient's T7 to T8 spinal processes, extend fingers laterally, ask the patient to exhale deeply, and observe lateral inward movement of the thumbs. d. Place the palmar side of each hand on the shoulders of the patient, ask the patient to sit up straight and take a deep breath, and observe symmetric movement of the shoulders.

B

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? a. "Have you also experienced tightness in your chest?" b. "Does the sputum have an odor?" c. "Have you coughed up any blood?" d. "Do you have chest pain when you take a deep breath?"

B

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

Fetid Sputum

Bacterial PNA or Lung Abscess

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 would the nurse anticipate? a. Bronchial breath sounds in the posterior thorax b. Decrease in respiratory rate c. Decreased breath sounds on auscultation d. Complaint of sharp chest pain on inspiration

C

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? a. Hair loss from the scalp b. Dry, flaky skin c. Clubbing of the fingers d. Hypertrophy of the nails

C

A nurse is assessing for vocal (tactile) fremitus on a patient with pulmonary edema. Which is the appropriate technique to use? a. Systematically percuss the posterior chest wall following the same pattern that is used for auscultation and listen for a change in tone from resonant to dull. b. Place the pads of the fingers on the right and left thoraces and palpate the texture and consistency of the skin feeling for a crackly sensation under the fingers. c. Place the palms of the hands on the right and left thoraces, ask the patient to say "99," and feel for vibrations. d. Place both thumbs on either side of the patient's spinal processes, extend fingers laterally, ask the patient to take a deep breath, and feel for vibrations.

C

A patient has an infection of the terminal bronchioles and alveoli that involves the right lower lobe of the lung. Which findings are expected a. Dyspnea with diminished breath sounds bilaterally b. Asymmetric chest expansion on the right side c. Fever and tachypnea with crackles over the right lower lobe d. Prolonged expiration with an occasional wheeze in the right lower lobe

C

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? a. Inspiratory wheezing found on auscultation b. Decreased breath sounds on auscultation c. Increased tactile fremitus and dull percussion tones d. Muffled sounds heard when the patient says "e-e-e"

C

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? a. Asymmetric expansion of the chest wall on inhalation b. Increased transmission of vocal vibrations on auscultation c. Crackling sensation under the skin of the chest on palpation d. Coarse grating sounds heard over the mediastinum on inspiration

C

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? a. Dull tones heard on percussion b. Increased vocal fremitus on palpation c. Decreased breath sounds on auscultation d. Complaint of sharp chest pain on inspiration

C

The nurse is palpating a patient's chest wall. What can be accomplished with palpation of the chest? a. Approximation of lung size b. Determination of oxygenation c. Assessment of equal chest expansion d. Identification of lung sounds

C

Which question gives the nurse further information about the patient's complaint of chest pain? a. "Have you had your influenza shot this year" b. "Are there environmental conditions that may affect your breathing at home" c. "How would you describe the chest pain" d. "Has the chest pain been interrupting your sleep at night"

C

During an assessment, the nurse knows that expected assessment findings in the normal adult lung include the presence of what? Select all that apply. a. Adventitious sounds and limited chest expansion b. Increased tactile fremitus and dull percussion tones c. Muffled voice sounds and symmetric tactile fremitus d. Absent voice sounds and hyperresonant percussion tones e. Symmetric chest f. Resonant percussion tones g. Expansion muffled voice sounds

C, E, F, G

Thick Sputum

Cystic Fibrosis

A patient is admitted to the emergency department with a tracheal obstruction. What sound does the nurse expect to hear as this patient breathes? a. Bubbling or rasping sounds heard over the trachea b. Soft, muffled rhonchi heard over the trachea c. Dull sounds on percussion (pneumonia, pleural effusion, or atelectasis) d. High-pitched sounds on inspiration and exhalation (stridor)

D

During the inspection of the respiratory system the nurse documents what finding as abnormal? a. Dyspnea with diminished breath sounds bilaterally b. Asymmetric chest expansion on the right side c. Fever and tachypnea with crackles over the right lower lobe d. Patient leaning forward with arms braced on the knees

D

How does the nurse palpate the chest for tenderness, bulges, and symmetry? a. Uses the fist of the dominant hand to gently tap the anterior, lateral, and posterior chest, comparing one side with another b. Uses the ulnar surface of one hand to palpate the anterior, posterior, and lateral chest, comparing one side with another c. With the tips of the fingers, palpates the skin over the chest and the alignment of vertebrae d. With the palmar surface of fingers of both hands, feels the consistency of the skin over the chest and alignment of vertebrae

D

The nurse auscultates prolonged expiration with expiratory wheezing and diminished breath sounds while assessing a patient. What does the nurse suspect? a. Tuberculosis b. Pneumonia c. Croup d. Asthma

D

Which breath sounds are expected over the posterior chest of an adult?

Vesicular

Usually produces a nonproductive cough

Virus

High pitched, musical end of inspiration; start of expiration. Increased thickness of airway (asthma)

Wheezes

Narrowing of the bronchi creates which adventitious sound?

Wheezing

The process by which oxygen and carbon dioxide move from areas of high concentration to areas of lower concentration is referred to as

diffusion

Respiratory rate within expected range

eupnea

Difficulty breathing when lying down

orthopnea

left plural cavity

parietal pleura visceral pleura lungs

SOB/feeling of suffocation that awakens the client at night

paroxysmal nocturnal dyspnea

Fluid in the pleural space

pleural effusion

rubbing/grating throughout the cycle. (pericarditis)

pleural friction rub

Sharp pain w/inhalation, caused by inflammation of the serous membranes lining the thorax

pleuritic pain

Pink, Frothy Sputum w/ Dyspnea

pulmonary edema

Low pitched, coarse, "snoring" mostly expiration. Most common in obstructive disorders

rhonchi

black sputum

smoke/dust inhalation

rust colored sputum

tb or pneumococcal pna

The RN is caring for a patient with a long hx of COPD (respiratory disease) who is experiencing an exacerbation. The RN knows that the client's positioning may be indicative of respiratory distress. What should the RN look for?

tripod position

Lungs, bone, lymphatics

tuberculosis

process of moving gasses in & out of the lungs is referred to as

ventilation

dry cough

viral

An exam technique; tests vibration felt from client's verbalization

vocal fremitus

On auscultation of a patient's lungs, the nurse hears low-pitched, coarse, loud, and low snoring sound. Which term does the nurse use to document this finding?

Rhonchi

Alveolar collapse; heard as rales on auscultation

atelectasis

productive cough

bacterial pneumonia