Chapter 18 (lungs&thora)

The nurse is assessing voice sounds during a respiratory assessment. Which of these findings indicates a normal assessment? Select all that apply.

-Voice sounds are faint, muffled, and almost inaudible when the patient whispers one, two, three in a very soft voice. -When the patient speaks in a normal voice, the examiner can hear a sound but cannot exactly distinguish what is being said. -As the patient says a long ee-ee-ee sound, the examiner also hears a long ee-ee-ee sound.

When performing a respiratory assessment on a patient, the nurse notices a costal angle of approximately 90 degrees. This characteristic is:

A normal finding in a healthy adult.

During palpation of the anterior chest wall, the nurse notices a coarse, crackling sensation over the skin surface. On the basis of these findings, the nurse suspects:

Crepitus.

A patient with pleuritis has been admitted to the hospital and complains of pain with breathing. What other key assessment finding would the nurse expect to find upon auscultation?

Friction rub

A patient has a long history of chronic obstructive pulmonary disease (COPD). During the assessment, the nurse will most likely observe which of these?

Anteroposterior-to-transverse diameter ratio of 1:1

A 65-year-old patient with a history of heart failure comes to the clinic with complaints of being awakened from sleep with shortness of breath. Which action by the nurse is most appropriate?

Assessing for other signs and symptoms of paroxysmal nocturnal dyspnea

An adult patient with a history of allergies comes to the clinic complaining of wheezing and difficulty in breathing when working in his yard. The assessment findings include tachypnea, the use of accessory neck muscles, prolonged expiration, intercostal retractions, decreased breath sounds, and expiratory wheezes. The nurse interprets that these assessment findings are consistent with:

Asthma.

The nurse is auscultating the lungs of a patient who had been sleeping and notices short, popping, crackling sounds that stop after a few breaths. The nurse recognizes that these breath sounds are:

Atelectatic crackles that do not have a pathologic cause.

When assessing tactile fremitus, the nurse recalls that it is normal to feel tactile fremitus most intensely over which location?

Between the scapulae

A patient has been admitted to the emergency department with a possible medical diagnosis of pulmonary embolism. The nurse expects to see which assessment findings related to this condition?

Chest pain that is worse on deep inspiration and dyspnea

When assessing a patients lungs, the nurse recalls that the left lung:

Consists of two lobes.

The nurse knows that a normal finding when assessing the respiratory system of an older adult is:

Decreased mobility of the thorax.

The primary muscles of respiration include the:

Diaphragm and intercostals.

The nurse is percussing over the lungs of a patient with pneumonia. The nurse knows that percussion over an area of atelectasis in the lungs will reveal:

Dullness.

The nurse is reviewing the characteristics of breath sounds. Which statement about bronchovesicular breath sounds is true? Bronchovesicular breath sounds are:

Expected near the major airways.

The left lung has two lobes, and the right lung has three lobes. The right lung is shorter than the left lung because of the underlying liver. The left lung is narrower than the right lung because the heart bulges to the left. The posterior chest is almost all lower lobes.

Extend 3 to 4 cm above the inner third of the clavicles.

The nurse is auscultating the chest in an adult. Which technique is correct?

Firmly holding the diaphragm of the stethoscope against the chest

A patient has been admitted to the emergency department for a suspected drug overdose. His respirations are shallow, with an irregular pattern, with a rate of 12 respirations per minute. The nurse interprets this respiration pattern as which of the following?

Hypoventilation

During percussion, the nurse knows that a dull percussion note elicited over a lung lobe most likely results from:

Increased density of lung tissue.

The nurse is reviewing the technique of palpating for tactile fremitus with a new graduate. Which statement by the graduate nurse reflects a correct understanding of tactile fremitus? Tactile fremitus:

Is caused by sounds generated from the larynx.

During auscultation of breath sounds, the nurse should correctly use the stethoscope in which of the following ways?

Listening to at least one full respiration in each location

The nurse is assessing the lungs of an older adult. Which of these changes are normal in the respiratory system of the older adult?

Lungs are less elastic and distensible, which decreases their ability to collapse and recoil.

During an assessment, the nurse knows that expected assessment findings in the normal adult lung include the presence of:

Muffled voice sounds and symmetric tactile fremitus.

A teenage patient comes to the emergency department with complaints of an inability to breathe and a sharp pain in the left side of his chest. The assessment findings include cyanosis, tachypnea, tracheal deviation to the right, decreased tactile fremitus on the left, hyperresonance on the left, and decreased breath sounds on the left. The nurse interprets that these assessment findings are consistent with:

Pneumothorax.

A patient comes to the clinic complaining of a cough that is worse at night but not as bad during the day. The nurse recognizes that this cough may indicate:

Postnasal drip or sinusitis.

When assessing the respiratory system of a 4-year-old child, which of these findings would the nurse expect?

Presence of bronchovesicular breath sounds in the peripheral lung fields

During auscultation of the lungs of an adult patient, the nurse notices the presence of bronchophony. The nurse should assess for signs of which condition?

Pulmonary consolidation

During a morning assessment, the nurse notices that the patients sputum is frothy and pink. Which condition could this finding indicate?

Pulmonary edema

A mother brings her 3-month-old infant to the clinic for evaluation of a cold. She tells the nurse that he has had a runny nose for a week. When performing the physical assessment, the nurse notes that the child has nasal flaring and sternal and intercostal retractions. The nurses next action should be to:

Recognize that these are serious signs, and contact the physician.

When inspecting the anterior chest of an adult, the nurse should include which assessment?

Shape and configuration of the chest wall

A 70-year-old patient is being seen in the clinic for severe exacerbation of his heart failure. Which of these findings is the nurse most likely to observe in this patient?

Shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, and ankle edema

he nurse is observing the auscultation technique of another nurse. The correct method to use when progressing from one auscultatory site on the thorax to another is _______ comparison.

Side-to-side

During an examination of the anterior thorax, the nurse is aware that the trachea bifurcates anteriorly at the:

Sternal angle.

The nurse knows that auscultation of fine crackles would most likely be noticed in:

The immediate newborn period.

Which of these statements is true regarding the vertebra prominens? The vertebra prominens is:

The spinous process of C7.

A 35-year-old recent immigrant is being seen in the clinic for complaints of a cough that is associated with rust-colored sputum, low-grade afternoon fevers, and night sweats for the past 2 months. The nurses preliminary analysis, based on this history, is that this patient may be suffering from:

Tuberculosis.

When auscultating the lungs of an adult patient, the nurse notes that low-pitched, soft breath sounds are heard over the posterior lower lobes, with inspiration being longer than expiration. The nurse interprets that these sounds are:

Vesicular breath sounds and normal in that location.

A woman in her 26th week of pregnancy states that she is not really short of breath but feels that she is aware of her breathing and the need to breathe. What is the nurses best reply?

What you are experiencing is normal. Some women may interpret this as shortness of breath, but it is a normal finding and nothing is wrong.

The nurse is listening to the breath sounds of a patient with severe asthma. Air passing through narrowed bronchioles would produce which of these adventitious sounds?

Wheezes

During an assessment of an adult, the nurse has noted unequal chest expansion and recognizes that this occurs in which situation?

When part of the lung is obstructed or collapsed

During auscultation of the lungs, the nurse expects decreased breath sounds to be heard in which situation?

When the bronchial tree is obstructed