HA - Unit 2 - Chapter 19: Assessing Thorax and Lungs

The nurse is assessing a client's progress in smoking cessation according to the Stages of Change Model. Which statement indicates that the client is in the Action stage? "I am not ready to quit, but I am concerned about my smoking habit." "I am ready to quit smoking." "I just quit smoking today." "I stopped smoking a year ago."

"I just quit smoking today." The statement "I just quit smoking today" indicates that the client is in the Action stage according to the Stages of Change Model. "I am not ready to quit, but I am concerned about my smoking habit" is consistent with the Contemplation stage. "I am ready to quit smoking" is consistent with the Preparation stage. "I stopped smoking a year ago" is consistent with the Maintenance stage.

Dyspnea, an uncomfortable awareness of breathing that is inappropriate to the level of exertion, is what? Audible breathing Painful breathing Air hunger Prolonged inspiration

Air hunger Dyspnea is air hunger, a nonpainful but uncomfortable awareness of breathing that is inappropriate to the level of exertion, commonly termed shortness of breath.

A hospitalized client experiences respiratory distress. The nurse should include which most appropriate client outcome in the plan of care? Gas exchange with oxygen saturation greater than 85% Airway patent, breathing quiet, denies dyspnea Client maintains safety; no falls Pain level stabilized at client goal

Airway patent, breathing quiet, denies dyspnea For a client experiencing respiratory distress, a respiratory related outcome is most appropriate such as patent airway, quiet breathing, and denying dyspnea. An appropriate client outcome for oxygen saturation is to maintain levels above 92%. Fall safety and pain are not respiratory-related outcomes.

A nurse hears adventitious lung sounds while auscultating a client's lung fields. What action should the nurse take? Ask the client to cough. Request a STAT chest x-ray. Notify the health care provider. Document the findings as normal.

Ask the client to cough If adventitious lung sounds are heard on auscultation, the nurse should have the client cough to try and clear the secretions and then auscultate again. Coughing may clear the secretions and improve lung sounds. A STAT x-ray is not required because no other signs and symptoms are discussed. The nurse will need to assess the client further before contacting the health care provider. The nurse will document the findings, but adventitious lung sounds would not be considered normal.

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 Change the client's position Compare the sound with the other side Listen again with the bell of the stethoscope

Ask the client to cough If an abnormal sound is heard during auscultation, always have the client cough and then listen again. Coughing may clear the lungs. There is no reason for the client to change position. Lung sounds should be compared but the abnormal sound needs to be addressed first. The diaphragm of the stethoscope is used to auscultate breath sounds.

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? Spontaneous pneumothorax Chronic obstructive pulmonary disease (COPD) Asthma Pneumonia

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.

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? Emphysema Lung cancer Sleep apnea Bacterial infection

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.

Adventitious sounds related to atelectasis and pulmonary edema are first evident when auscultating what area of the respiratory system? Bronchi Bases Apices Trachea

Bases Careful auscultation of the bases is important because they are often the first area to collapse with atelectasis when a client is immobile. This is also where fluid collects in a pleural effusion (outside the lungs) or with pulmonary edema (in the lungs) in heart failure.

A nurse performs a respiratory assessment on a client and notes the respiratory rate to be 8 breaths per minute. The nurse knows the proper term for this rate is what? Bradypnea Tachypnea Hyperventilation Hypoventilation

Bradypnea A respiratory rate of less than 10 breaths per minute is called bradypnea. Tachypnea is a respiratory rate greater than 24 breaths per minute. Hyperventilation is used to describe respirations that are increased in rate and depth. Hypoventilation is a rate that is decreased, with a decrease in depth and with an irregular pattern.

Which lung sound possesses the following characteristics? Expiration is longer than inspiration; the sound is louder and higher in pitch with a short silence between inspiration and expiration. Bronchovesicular Vesicular Bronchial Tracheal

Bronchial These characteristics are consistent with bronchial breath sounds. Be alert for these because they may occur elsewhere and indicate pneumonia or other pathology. The current explanation for this phenomenon is that fluid carries the sound from the trachea very well to the chest wall. This same explanation explains 'ee' to & 'aa' changes, whispered pectoriloquy, bronchophony, and others in which high-frequency sounds, normally blocked by air-filled alveoli, could be transmitted to the chest wall.

The nurse prepares to assess a client's breath sounds. Where should bronchial sounds occur?

Bronchial sounds are heard over the trachea.

Which of the following statements relating to assessment of the lungs and thorax is most accurate? 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. Loud and very loud percussion notes denote pathological findings. 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 color of sputum would support the diagnosis of heart failure? White Yellow 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.

What type of respiratory pattern would the nurse consider normal in a client with severe heart failure? Biot's Bradypnea Kussmaul Cheyne-Stokes

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.

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? Carcinoma of the lungs Pneumothorax Chronic obstructive pulmonary disease Tuberculosis

Chronic obstructive pulmonary disease An increase in the ratio of anteroposterior to transverse diameter is seen in clients with chronic obstructive pulmonary disease. This occurs because of air trapped in the airways that causes hyperinflation and overdistention. Carcinoma of the lungs, pneumothorax, and tuberculosis do not change the chest diameter.

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? Fine crackles Coarse crackles Sibilant wheeze 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.

A person with a barrel chest has a problem doing what? Taking a deep breath Coughing Expelling excess oxygen Breathing at a normal respiratory rate

Taking a deep breath Auscultation of all lung fields may not be possible because deep breathing generally worsens the level of fatigue in clients with pulmonary disorders.

During the assessment of a client with a pneumothorax, what change should the nurse anticipate when auscultating for fremitus? Symmetric Decreased Absence Increased

Decreased The nurse should find decreased fremitus in the client diagnosed with pneumothorax. Fremitus is the vibration of air in the bronchial tubes transmitted to the chest wall which is normally symmetrical. Unequal fremitus can be increased or decreased as a result of consolidation, bronchial obstruction, air trapping due to emphysema, pleural effusion, or pneumothorax. Absence of fremitus is not a physiological finding.

A nurse palpates for tactile fremitus and notes that the vibrations diminish towards the base of the lungs. What should the nurse recognize about this finding? An area of consolidation is present Client needs to speak louder Atelectasis has occurred Decreasing intensity is normal at the base

Decreasing intensity is normal at the base Fremitus should be symmetrical and easily identifiable in the upper lobes. A decrease in intensity is normal when moving towards the base of the lungs. Unequal fremitus is a result of consolidation, bronchial obstruction, air trapping, pleural effusion, or pneumothorax. Speaking louder would be necessary if no vibrations were felt at any location on the thorax.

Which of the following muscles is primarily responsible for thoracic cavity enlargement? Scalene Diaphragm Parasternal Sternomastoid

Diaphragm The diaphragm is the primary muscle of inspiration; when it contracts, its descent enlarges the thoracic cavity.

What replaces resonance when fluid or solid tissue replaces air-containing lung or occupies the pleural space? Hyperresonance Dullness Tympany Chief complaint

Dullness Dullness replaces resonance when fluid or solid tissue replaces air-containing lung or occupies the pleural space.

A client in the ED tells the nurse that she is having difficulty breathing at rest. What term would the nurse use in documenting this finding? Dyspnea Tachypnea Shortness of breath Anxiety

Dyspnea Dyspnea is a subjective term used when the client reports labored breathing and breathlessness. This response to exercise or heavy activity is normal if it rapidly disappears upon return to rest. Difficulty breathing, in appropriate medical terminology, is not tachypnea, shortness of breath, or anxiety.

A client with lobar pneumonia would have muffled and indistinct spoken voice sounds. True False

False

Which characteristic feature of the sternum should the nurse observe in a client with the diagnosis of pectus carinatum? Sunken along with the adjacent cartilages Forward protrusion Midline and straight Horizontal sternum with increased intercostal angle

Forward protrusion A client with pectus carinatum has a forward protrusion of the sternum causing the adjacent ribs to slope backward. Sunken sternum and adjacent cartilages are seen in funnel chest. Midline and straight position of the sternum is the normal anatomical position. Horizontal sternum with increased intercostal angle is seen in barrel chest.

What would the nurse expect to hear when auscultating the lungs of a client diagnosed with pleuritis? Friction rub Decreased breath sounds Sibilant wheeze 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 Pigeon chest Intercostal bulging Pectoriloquy

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 Funnel chest (pectus excavatum) Pigeon chest (pectus carinatum) Thoracic kyphoscoliosis

Funnel chest (pectus excavatum) Funnel chest is caused by a depression in the lower portion of the sternum. If severe enough there can be compression of the heart and great vessels, leading to murmurs on auscultation. This is usually only a cosmetic problem, but corrective surgeries can be performed if necessary.

The thoracic cavity contains which of the following organs? Select all that apply. Heart Lungs Most of the esophagus Stomach Pancreas

Heart Lungs Most of the esophagus The cavity contains the heart, lungs, thymus, distal part of the trachea, and most of the esophagus. It does not contain the stomach or the pancreas.

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? Pneumonia-related dyspnea Tuberculosis-related cough Bronchitis 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 has a history of emphysema. The nurse percussing the client's chest expects to hear what characteristic sound? Hyperresonance Dullness Resonance Tympany

Hyperresonance Hyperresonance would be noted in a client with emphysema due to air trapping. Dullness is noted with fluid or solid tissue replacing air in the lung. Resonance is the normal finding on lung percussion. Tympany would be noted over areas of air, such as a gastric bubble in the stomach.

A nurse assesses the respiration pattern on a client who arrives in the emergency department due to an overdose of narcotics. The nurse notes that the respirations are decreased in rate and depth, and have an irregular pattern. How should the nurse document this finding? Cheyne-Stokes respiration Biot's respiration Hypoventilation Bradypnea

Hypoventilation Hypoventilation is decreased rate, decreased depth, and irregular pattern of respiration. A client with regular pattern characterized by alternating periods of deep, rapid breathing followed by periods of apnea has Cheyne-Stokes respiration. A client with irregular pattern characterized by varying depth and rate of respirations followed by periods of apnea has Biot's respiration. A client with bradypnea may have a regular respiration rate of less than 10/min.

A nurse is auscultating the bronchi of a client. The nurse understands that the bronchi are located in which of the following locations in the body? At the level of the 12th rib on the left scapular line In the mediastinum At the level of the 8th rib on the right mid-clavicular line At the base of the lungs

In the mediastinum The thoracic cavity consists of the mediastinum and the lungs, and is lined by the pleural membranes. The mediastinum refers to a central area in the thoracic cavity that contains the trachea, bronchi, esophagus, heart, and great vessels.

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 Impaired Gas Exchange Ineffective Breathing Pattern

Ineffective Airway Clearance The nurse observes the client's inability to cough up secretions which is a major defining characteristic for accepting the nursing diagnosis of Ineffective Airway Clearance. There is no indication that this client has or is at risk for an infection. Impaired Gas Exchange can not be confirmed because there is no indication that the client is having poor muscle tone or has damage to lung tissue. For Ineffective Breathing Pattern to be confirmed the client must demonstrate a pattern of hyper or hypoventilation.

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 Instruct the client to cough forcefully Have the client breathe through the mouth Assess for the use of accessory muscles

Instruct the client to cough forcefully When auscultating crackles in the lung fields, the nurse should instruct the client to cough forcefully in an effort to open the airways. Then the nurse should auscultate again and note any changes. Lung sounds should be listened to with the diaphragm because they are high-pitched sounds. The bell is used for low-pitched sounds such as abnormal heart sounds. Breathing through the mouth lets the air in quicker but will not clear the airways. Use of accessory muscles is seen with respiratory distress.

How should a nurse position a client to accurately auscultate the right middle lobe of the lung? Lateral with the right lung facing up Lean forward at the waist Rest the arms on the knees Move the right arm away from the body

Move the right arm away from the body The right middle lobe of the lung is located in the midaxillary region and extends anteriorly. Therefore, the right middle lobe must be assessed from the anterior surface of the chest. This is best accomplished by asking the client to move the right arm away from the body and auscultating in the midaxillary area on the right. The other positions do not allow the right middle lobe to be exposed for auscultation.

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 Palpate for tactile fremitus Percuss to determine diaphragmatic excursion Observe for the use of accessory muscles

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? Report this to the health care provider immediately Assess for symmetry of chest expansion Observe the client's respiratory rate and pattern Ask the client how long they have to rest between activities

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.

The nurse demonstrates appropriate technique when using what part of the hand to assess for fremitus in a client? Dorsal hand surface Pads of fingers Palmar base Fist

Palmar base The palmar base or ulnar surface of the hand is best for assessing tactile fremitus because the area is especially sensitive to vibratory sensation. The dorsal surface of the hand is used to assess temperature. The fist is used in blunt percussion. Finger pads are used for fine discrimination such as pulses, texture, and size.

While performing an assessment of a client who sustained a chest injury, which physical examination technique should the nurse use to elicit crepitus? Palpation Auscultation Percussion Inspection

Palpation The nurse should use the palpation technique to elicit crepitus. Crepitus is a crackling sensation that occurs when air passes through fluid or exudate. Auscultation, percussion, and inspection cannot elicit crepitus because it is air trapped into the tissue around the lungs.

During a comprehensive physical assessment at a home visit, a client reports chest discomfort. What is the first action of the nurse? Perform a focused assessment. Notify the health care provider immediately. Continue the comprehensive assessment. Call for an ambulance.

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.

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 Gastric air bubble Emphysema Pleural effusion

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 Asthma Rales

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.

During a physical assessment, the nurse identifies unequal chest expansion. The nurse knows this could be due to what? Select all that apply. Pneumonia Atelectasis Trauma Pneumothorax Emphysema

Pneumonia Atelectasis Trauma Pneumothorax Decreased chest excursion is seen with emphysema. Asymmetrical chest movements may be due to pneumonia, pneumothorax, trauma or atelectasis.

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? Spontaneous pneumothorax Chronic obstructive pulmonary disease (COPD) Asthma Pneumonia

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? Pneumothorax Atelectasis Muscular weakness Asthma

Pneumothorax Breath sounds may be decreased when air flow is decreased (as in obstructive lung disease or muscular weakness) or when the transmission of sound is poor (as in pleural effusion, pneumothorax, or COPD).

The nurse prepares to auscultate a client's lung sounds. Where on the diagram should the nurse place the stethoscope to hear sounds in the left upper lobe?

Posteriorly, the upper lobes are auscultated above the level of the scapula.

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 Pulmonary edema Infection 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? Hyperresonance Dullness Resonance Tympany

Resonance Normal lung tissue elicits a resonance tone when percussed. Hyperresonance is elicited in cases of trapped air such as in emphysema or pneumothorax. Dullness may characterize areas of increased density such as consolidation, pleural effusion, or tumor. Tympany is elicited over air filled spaces such as puffed out check or stomach bubble.

When percussing the posterior lung fields, which of the following findings is expected? Hyperresonance over apices Dullness over the lung bases Resonance over all lung fields Tympany over 11th interspace, right scapular line

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 client arrives in the emergency department after a severe motor vehicle accident. The nurse observes irregular respirations of varying depth and rate followed by periods of apnea. What pathophysiological process is likely the cause of this breathing pattern? Diabetic ketoacidosis Renal failure Narcotic overdose Severe brain damage

Severe brain damage The respiratory pattern observed is Biot's respirations that may be seen with meningitis or severe brain damage. Diabetic ketoacidosis would reveal Kussmaul respirations that are characterized by an increased rate and depth. Renal failure would reveal Cheyne-Stokes respirations characterized by a regular pattern of alternating deep and rapid breathing with periods of apnea. A narcotic overdose would reveal hypoventilation or possibly Cheyne-Stokes respirations.

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 Course crackles occurring from early inspiration to early expiration Sibilant wheezes heard primarily during expiration but may also be heard on 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 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? The client speaks in sentences of 10-20 words. Skin between the ribs moves inward with inspiration. Neck muscles are relaxed. Client torso leans posteriorly.

Skin between the ribs moves inward with inspiration. This description is consistent with retractions, which occur with respiratory distress. Other features include speaking in short sentences, use of accessory muscles, leaning forward to gain mechanical advantage for the diaphragm, and pursed lip breathing in which the client exhales against the lips, which are pressed together.

A client is admitted to the health care facility with a diagnosis of left lower lobe pneumonia. What change in egophony should the nurse expect to find in the left lower lobe? "Ninety nine" is soft and muffled Letter "E" is heard distinctly "1-2-3" is heard clearly Sound is louder and sounds like "A"

Sound is louder and sounds like "A" To perform egophony, the nurse asks the client to repeat the letter "E" while listening with the stethoscope. Over normal lung tissue, the sound will be soft and muffled but the letter should be distinguishable. In areas of consolidation, such as pneumonia, the letter "E" will sound louder and sound like the letter "A". Bronchophony uses the words "Ninety nine". Whispered pectoriloquy uses the phrase "1-2-3".

What is the best guide to make vertical locations on the chest? Midclavicular line Sternal angle Angle of Henri 5th intercostal space

Sternal angle To make vertical locations, you must be able to count the ribs and interspaces. The sternal angle, also termed the angle of Louis, is the best guide.

A high-pitched crowing sound from the upper airway results from tracheal or laryngeal spasm and is called what? Stridor Crackles Wheezes Rales

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? Suprasternal notch Sternal angle Acromion of the scapula Xiphoid process

Suprasternal notch The sternum, or breastbone, lies in the center of the chest anteriorly and is divided into three parts: the manubrium, the body, and the xiphoid process. The manubrium connects laterally with the clavicles (collar bones) and the first two pairs of ribs. The clavicles extend from the manubrium to the acromion of the scapula. A U-shaped indentation located on the superior border of the manubrium is an important landmark known as the suprasternal notch. A few centimeters below the suprasternal notch, a bony ridge can be palpated at the point where the manubrium articulates with the body of the sternum. This landmark, often referred to as the sternal angle (or angle of Louis), is also the location of the second pair of ribs and becomes a reference point for counting ribs and intercostal spaces.

When assessing posteriorly, where would the trachea bifurcate into its mainstem bronchi? Sternal angle T4 spinous process Suprasternal notch Midaxillary line

T4 spinous process The trachea bifurcates into its mainstem bronchi at the levels of the sternal angle anteriorly and the T4 spinous process posteriorly.

Chest expansion

The nurse is assessing for lung symmetry when the hands are placed equidistant on the posterior chest. A stethoscope is needed to assess breath sounds. The client repeats a word when tactile fremitus is assessed. Percussion is used to assess for tissue consolidation.

The nurse prepares to auscultate a client's breath sounds. Where should the nurse place the stethoscope to hear the sounds from the client's middle lobe?

The right middle lobe is located between the 3rd and 5th intercostal space, midclavicular line, on the right side of the chest.

Which observation confirms to the nurse that the client is experiencing a normal inspiration? The thoracic cavity enlarges. The abdominal wall is pushed inward. Air can be heard moving out of the tracheobronchial tree. The diaphragm is seen relaxing.

The thoracic cavity enlarges. The diaphragm is the primary muscle of inspiration. When it contracts during inhalation, it descends in the chest and enlarges the thoracic cavity. At the same time, it compresses the abdominal contents, pushing the abdominal wall outward. Intrathoracic pressure decreases, drawing air through the tracheobronchial tree into the alveoli, or distal air sacs, and expanding the lungs. It is during expiration that the diaphragm relaxes.

Which characteristic associated with respiratory effort should be considered when planning care for a client diagnosed with a brainstem injury? There is loss of involuntary respiratory control. The client will respond negatively to increased stimuli. There is an increased level of carbon dioxide in the blood. 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.

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 wheezes fine crackles 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.

A young toddler is brought to the emergency room by his parents. The mother states that the child was playing on the floor with toys and suddenly began to wheeze. The mother reports no recent illnesses. The nurse suspects that the most likely cause of the wheezing is a foreign body obstruction increased secretions a severe cold exercise-induced asthma

a foreign body obstruction

A bony ridge located at the point where the manubrium articulates with the body of the sternum is termed the sternal angle. notch. space. prominens.

angle. A few centimeters below the suprasternal notch, a bony ridge can be palpated at the point where the manubrium articulates with the body of the sternum. This landmark, often referred to as the sternal angle (or angle of Louis), is also the location of the second pair of ribs and becomes a reference point for counting ribs and intercostal spaces.

The nurse is preparing to auscultate the posterior thorax of an adult female client. The nurse should place the bell of the stethoscope firmly on the posterior chest wall. auscultate from the base of the lungs to the apices. ask the client to breathe deeply through her mouth. ask the client to breathe normally through her nose.

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 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.

The lining of the trachea and bronchi, which serves to remove dust, foreign bodies, and bacteria, is termed the bronchioles. alveolar sacs. alveolar ducts. cilia.

cilia The trachea and bronchi are lined with mucous membranes containing cilia. These hair-like projections help sweep dust, foreign bodies, and bacteria that have been trapped by the mucus toward the mouth for removal.

The nurse percusses the lungs of a client with pneumonia. What percussion note would the nurse expect to document? dullness hyperresonance tympany flatness

dullness

Under normal circumstances, the strongest stimulus to breathe is hypoxemia. hypocapnia. pH changes. hypercapnia.

hypercapnia. Under normal circumstances, the strongest stimulus to breathe is an increase of carbon dioxide in the blood (hypercapnia).

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 Generalized hyperresonance may be heard over hyperinflated lungs found in clients with emphysema, a chronic lung disease. A flat sound may be heard if a pleural effusion is present. A dull sound may be heard if the client has lobar pneumonia. Resonance is the expected sound heard over healthy lung tissue.

The client reports severe pain when breathing in deeply. The description suggests to the nurse that the client is experiencing which respiratory condition? ineffective innervation of the of the parietal pleura by the phrenic nerve an accumulation of fluid between the lungs and the visceral pleura inflammation of the parietal pleura an increase of sensory stimulation in the visceral pleura

inflammation of the parietal pleura Inflammation of the parietal pleura produces pleuritic pain with deep inspiration, e.g., in pleurisy, pneumonia, and pulmonary embolism. The visceral pleura lies next to the lung, and the parietal pleura lines the inner rib cage and upper surface of the diaphragm. The visceral pleura lacks sensory nerves, but the parietal pleura is richly innervated by the intercostal and phrenic nerves.

A nurse is palpating the sternum of a client. If the client is healthy, which of the following would characterize his costal angle? 110 degrees 45 degrees 100 degrees less than 90 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.

The clavicles extend from the acromion of the scapula to the part of the sternum termed the body. xiphoid process. angle. manubrium.

manubrium. The clavicles extend from the manubrium to the acromion of the scapula.

Identify the location where vesicular, bronchovesicular, bronchial, and tracheal lung sounds are heard (in that order). over most of both lungs over the manubrium over the trachea in the neck between the scapulae

over most of both lungs between the scapulae over the manubrium over the trachea in the neck

Which pleural membrane lines the chest cavity? pulmonary pleura parietal pleura visceral pleura thoracic pleura

parietal pleura The thin, double-layered serous membrane that lines the thoracic cavity is called the pleura. The parietal pleura is the layer which lines the chest cavity, and the visceral pleura covers the exterior of the lungs.

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 thorax. pectus excavatum. pectus carinatum. pectus diaphragm.

pectus excavatum. Pectus excavatum is a markedly sunken sternum and adjacent cartilages (often referred to as funnel chest). It is a congenital malformation that seldom causes symptoms other than self-consciousness.

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 pneumonia. pleuritis. bronchitis. asthma.

pneumonia. Crackles occurring late in inspiration are associated with restrictive diseases such as pneumonia.

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 phrase "ninety-nine." repeat the letter "E." whisper the phrase "one-two-three." repeat the letter "A."

repeat the phrase "ninety-nine." To assess bronchophony ask the client to repeat the phrase "ninety-nine" while you auscultate the chest wall.

Which accessory muscles are most important when considering inspiratory breathing needs during exercise? abdominal muscles lateral neck muscles sternocleidomastoids intercostal muscles

sternocleidomastoids During exercise and in certain diseases, extra work is required to breathe, and accessory muscles join the inspiratory effort. The sternocleidomastoids are the most important of these, and the scalenes may become visible. Abdominal muscles assist in expiration. Intercostals and neck muscles are involved in all respirations.

What action by the nurse when percussing a client's chest will help maximize the resulting vibrations? delivering quick, sharp but relaxed strikes to the chest positioning the right forearm close to the surface of the chest touching the chest with only the pleximeter finger striking the pleximeter finger with the right or middle finger

touching the chest with only the pleximeter finger Making surface contact between any other part of the hand, except the finger, and the chest will result in a dampening out of the vibrations. The remaining options present correct information, but these actions are not directly associated with maximizing the resulting vibrations.

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 pulmonary edema. bronchitis. asthma. tuberculosis.

tuberculosis. Rust-colored sputum is associated with tuberculosis or pneumococcal pneumonia.

Which terms are used to identify the lobes of the right lung? Select all that apply. upper lobe middle lobe lower lobe base lobe major lobe

upper lobe middle lobe lower lobe Anteriorly, this fissure runs close to the 4th rib and meets the oblique fissure in the midaxillary line near the 5th rib. The right lung is thus divided into upper, middle, and lower lobes. The left lung has only two lobes, upper and lower. Neither base nor major are terms used to identify the lobes of the lung.

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? bronchovesicular vesicular bronchial tracheal

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.