(N125/2) Ch 18

A young adult patient comes to the emergency department complaining of difficulty breathing. The person appears cyanotic and uses accessory neck muscles. The nurse hears audible wheezing. There is decreased tactile fremitus with hyperresonant sounds on percussion. Normal breath sounds are distant and hard to hear because of wheezing. Which disorder does the nurse suspect? 1. Asthma 2. Bronchitis 3. Pneumonia 4. Atelectasis

1 Rationale: Asthma is an allergic hypersensitivity characterized by bronchospasm and inflammation, edema in the walls of the bronchioles, and secretion of highly viscous mucus into the airways. These greatly increase the airway resistance, especially during expiration, and produce the symptoms of wheezing, dyspnea, and chest tightness. During a severe attack, there is an increased respiratory rate, shortness of breath with audible wheezes, use of accessory neck muscles, and cyanosis. Bronchitis is an illness that affects the lungs. It is caused by the inflammation or infection of the lining of the bronchial tubes. Pneumonia is an infection in one or both lungs caused by microbes. Pneumonia causes inflammation in the lung's air sacs. Atelectasis is defined as the collapse or closure of the lung resulting in reduced or absent gas exchange.

The nurse is assessing a patient for shortness of breath (SOB). What term should the nurse use to document excessive sweating associated with shortness of breath? 1. Diaphoresis 2. Chronic dyspnea 3. Two-pillow orthopnea 4. Paroxysmal nocturnal dyspnea

1 Rationale: Diaphoresis is excessive sweating, which can be related to shortness of breath. Chronic dyspnea is SOB lasting for more than 1 month. It may have neurogenic, respiratory, or cardiac origin. Orthopnea refers to difficulty in breathing when a person is lying in the supine position. If the patient requires two pillows to breathe comfortably while lying down, the nurse notes the condition as two-pillow orthopnea. A patient with paroxysmal nocturnal dyspnea may awaken from sleep with SOB. This patient may need to be upright in order to achieve comfort.

While auscultating the chest, the nurse asks the patient to phonate a long "ee-ee-ee-ee" sound. Through the stethoscope, the nurse hears a long "aaaaa" sound. Which voice sound is present? 1. Egophony 2. Bronchophony 3. Sonorous wheezing 4. Whispered pectoriloquy

1 Rationale: Egophony in Greek means "the voice of a goat" and occurs when there is any consolidation or compression of the chest. The nurse auscultates the chest while the patient makes a long "ee-ee-ee-ee" sound. Through the stethoscope, the nurse hears a bleating long "aaaaa" sound. This change of sound occurs over the area of consolidation or compression. In bronchophony, the patient is asked to repeat "ninety-nine." Through the stethoscope, the words are more distinct than normal, and the sounds are close to the ears of the nurse. This occurs when the pathology increases the lung density. In whispered pectoriloquy, the patient is asked to whisper a phrase such as "one-two-three." The nurse auscultates through the stethoscope to hear a clear, distinct, but faint whispering sound. A sonorous wheeze used to be known as rhonchi; the sounds produced have a snoring and gurgling quality.

What finding does the nurse identify as normal when assessing the chest of an elderly patient? 1. The patient has an outward curvature noted in the thoracic spine. 2. The respirations are deeper, with 40% increase in the tidal volume. 3. The costal angle is about 50% wider than seen in the younger adult. 4. The anteroposterior diameter is less than the transverse diameter.

1 Rationale: Kyphosis, or an outward curvature of the thoracic spine, is a normal finding in elderly patients. The person compensates by holding their head extended and tilted back. It is normal to find that the respirations are deeper with a 40% increase in the tidal volume in the pregnant patient, but not in the elderly patient. The thoracic cage appears wider and the costal angle widens by about 50% in the pregnant patient, but not in the elderly patient. The aging adult has a barrel-shaped chest, with the anteroposterior diameter equal to the transverse diameter.

The nurse notices that a patient occasionally sighs when breathing. What should the nurse expect to happen as a result of sighing? 1. It expands the alveoli. 2. It leads to tachypnea. 3. It causes hypoventilation. 4. It leads to slow breathing.

1 Rationale: Occasional sighing punctuates the normal breathing pattern and helps to expand the alveoli. Frequent sighing may indicate emotional dysfunction, leading to hyperventilation and dizziness. It does not cause tachypnea or rapid, shallow breathing; instead, it may increase the rate and the depth of breathing. Occasional sighing causes hyperventilation, not hypoventilation, and does not lead to bradypnea or slow breathing.

What is the main function of the respiratory system? 1. It helps in supplying oxygen to the body 2. It helps in the trapping of energy. 3. It helps in the production of carbon dioxide. 4. It helps in the movement of air in and out of the chest.

1 Rationale: Respiration is the oxidative breakdown of carbohydrates to produce energy. Oxygen is utilized in this process. Respiration does not trap energy; rather, it produces energy. The process called photosynthesis traps energy. Air is moved in and out of the chest by the process of breathing. Respiration is a biochemical process in which carbon dioxide is produced as a byproduct. The body does not require carbon dioxide.

Which group of patients is likely to be affected by scoliosis? 1. Adolescents 2. Menopausal women 3. Postmenopausal women 4. Women who exercise regularly

1 Rationale: Scoliosis is prevalent in the adolescent group, especially in girls. Mild deformities are asymptomatic, but any deviation greater than 45 degrees increases the risk for impaired cardiopulmonary function. Kyphosis is associated with aging and is common among women, much before menopause. Kyphosis is also known as the dowager's hump of postmenopausal women and is related to physical fitness. Women who exercise regularly are less likely to develop kyphosis.

How are the intercostal spaces of the thorax numbered? 1. By the ribs present above the spaces 2. By the vertebrae attached to the spaces 3. By the tracheal rings present below the spaces 4.By the intercostal muscles attached to the spaces

1 Rationale: The intercostal space is the anatomic space between the two ribs. Because there are 12 ribs on each side, there are 11 intercostal spaces, each numbered for the rib above it. Vertebrae are not attached to the intercostal spaces. Tracheal rings are parts of the trachea and are not related to the intercostal spaces. The intercostal spaces are not numbered by the intercostal muscles attached to the spaces.

What should the nurse expect to feel while palpating a patient's chest wall after undergoing thoracic surgery? 1. Crepitus 2. Rhonchal fremitus 3. Decreased fremitus 4. Pleural friction fremitus

1 Rationale: The nurse is likely to feel crepitus, which is a coarse, crackling sensation palpable over the skin surface. Crepitus occurs when air escapes from the lung and enters the subcutaneous tissue after open thoracic surgery. Rhonchal fremitus is palpable with thick bronchial secretions. Decreased fremitus occurs with obstructed bronchus, pleural effusion, or thickening. Pleural friction fremitus is palpable with the inflammation of the pleura.

During the chest assessment of a patient, which reference line does the nurse note on the posterior chest wall? 1. The midspinal line 2. The midaxillary line 3. The midsternal line 4. The midclavicular line

1 Rationale: The nurse notes the midspinal line, also known as the vertebral line, on the posterior chest wall. The nurse notes the midaxillary line when the patient's arm is lifted at an angle of 90 degrees. The midaxillary line runs down from the apex of the axilla and lies between and parallel to the anterior axillary line and the posterior axillary line. The midsternal and midclavicular lines are noted on the anterior chest.

How deep can a percussion of the chest penetrate? 1. 5 to 7 cm 2. 7 to 9 cm 3. 9 to 11 cm 4. 11 to 13 cm

1 Rationale: The nurse percusses the lung fields to determine the predominant notes. The depth of the penetration of percussion has limits. Percussion sets into motion only the outer 5 to 7 cm of tissue. It does not penetrate to reveal any change in the density deeper than that.

The nurse is assessing the bronchial breath sounds of a patient. Where should the nurse place the stethoscope? 1. Over the trachea and the larynx 2. Over the peripheral lung fields 3. Posterior between the scapulae 4. Anterior near the upper sternum

1 Rationale: The nurse should place the stethoscope over the trachea and the larynx to listen to bronchial breath sounds. These sounds have a high pitch, loud amplitude, with a harsh or hollow tubular quality. The nurse auscultates over the peripheral lung fields to note vesicular breath sounds. The nurse listens for bronchovesicular breath sounds over major bronchi with fewer alveoli. These are found on the posterior side between the scapulae and on the anterior side around the upper sternum and in the first and second intercostal spaces.

What abnormality would the nurse expect in a patient with kyphosis? 1. A condition that involves the rotation of the vertebrae 2. An exaggerated posterior curvature of the thoracic spine 3. A lateral S-shaped curvature of the thoracic and lumbar spine 4. An unequal shoulder and scapular height and unequal hip levels

1 Rationale: The patient with kyphosis has a humpback or an exaggerated posterior curvature of the thoracic spine. The patient may hyperextend the neck to maintain a level of vision. Scoliosis is a condition that involves the rotation of the vertebrae. The patient with scoliosis has a lateral S-shaped curvature of the thoracic and lumbar spine. Scoliosis causes unequal shoulder and scapular height and unequal hip levels.

What is a normal feature of the right lung that the nurse should be aware of? 1. It is shorter than the left lung. 2. It has an upper and lower lobe. 3. It is narrower than the left lung. 4. Its lobes sit as horizontal bands.

1 rationale: The lungs are paired, but asymmetrical, structures. The right lung is shorter than the left lung because of the presence of the liver, which sits just under the right lung. The right lung has three, not two, lobes: an upper, middle, and lower lobe. The left lung only has two lobes: an upper lobe and a lower lobe. The left lung is narrower than the right lung because the heart bulges to the left. The lobes of neither lung are set as horizontal bands: instead, they are stacked in diagonal sloping segments and are separated by fissures that run obliquely through the chest.

Which additional muscles are involved in increasing the size of the thoracic cage during forced inspiration after heavy exercise? 1. Scaleni 2. Trapezii 3. Diaphragm 4. Sternomastoids 5. Intercostal muscles

1, 2, 4 Rationale: During forced inspiration after heavy exercise, the accessory neck muscles move up the sternum and rib cage. These neck muscles are called scaleni, trapezii, and sternomastoids. During normal inspiration, the bell-shaped diaphragm contracts, descends, and flattens, which lengthens the vertical diameter. The intercostal muscles lift the sternum and elevate the ribs, making them more horizontal, thereby increasing the anterior-posterior diameter.

The nurse is assessing the anterior chest of a patient. Which assessment findings need further investigation? 1. The patient breathes through pursed lips. 2. The costal angle is greater than 90 degrees. 3. The facial expression is benign and relaxed. 4. The abdominal muscles indicate hypertrophy. 5. The ribs are sloping downwards symmetrically.

1, 2, 4 Rationale: The patient breathes through pursed lips to exhale slowly. This allows the pressure in the bronchial tree to remain positive and fewer airways collapse. It is an indication of chronic obstruction pulmonary disease (COPD) and needs further investigation. If the costal angle is greater than 90 degrees, the patient has a barrel chest. A barrel chest is the result of equal anteroposterior-to-transverse diameter and ribs that are horizontal. This condition must be investigated further, because it often occurs with chronic emphysema and asthma as a result of the hyperinflation of lungs. Hypertrophy of the abdominal muscles occurs in chronic emphysema and needs further investigation. A patient without breathing difficulty will have a benign and relaxed facial expression. In the normal chest, the ribs slope downward with symmetric interspaces and a costal angle less than 90 degrees.

The nurse is caring for a patient with pectus excavatum. What are the characteristics of this condition? 1. The patient has a markedly sunken sternum. 2. The condition is congenital, not symptomatic. 3. The ribs slope back on either side of the sternum. 4. The depression is more noticeable on inspiration. 5. The depressions are at the costochondral junction.

1, 2, 4 Rationale: The patient with pectus excavatum has a markedly sunken sternum and adjacent cartilages. This condition is also known as funnel breast. It is congenital, but not a symptomatic condition. Surgery may be indicated if the sternal depression is severe. Depression begins at the second intercostal space, becoming depressed mostly at the junction of the xiphoid with the body of the sternum. It is more noticeable on inspiration. Pectus carinatum, or pigeon breast, is a condition in which the sternum protrudes forward. The ribs slope back at either side and the vertical depressions are present along the costochondral junctions.

In ________________, the patient is asked to whisper a phrase such as "one-two-three." The nurse auscultates through the stethoscope to hear a clear, distinct, but faint whispering sound.

whispered pectoriloquy

What action should the nurse include when auscultating the anterior chest of a patient for breath sounds? 1. Starts the auscultation at the apices in the supraclavicular areas 2. Auscultates and listens for one full respiration in each location 3. Examines one side completely and then examines the other side 4. Listens with a stethoscope over the breast in the female patient 5. Completes the examination by auscultating down to the sixth rib

1, 2, 5 Rationale: The nurse should begin auscultating at the apices in the supraclavicular areas. This allows the nurse to listen from the very top of the lungs. The nurse must listen to one full respiration in each location for any adventitious lung sounds, because they may be heard in inspiration, expiration, or both. The nurse moves downward all the way down to the sixth rib to hear the bases of the lungs. The nurse must examine the chest from side to side while moving down to compare the sounds in the right and left lung. The nurse must not place the stethoscope directly over the female patient's breast, because this will prevent the nurse from clearly hearing the lung sounds. The nurse must listen directly over the chest wall after displacing the breast for accurate results.

Which changes take place during the process of inspiration? 1. The diaphragm descends. 2. The elastic recoil property acts. 3. The intercostal muscles contract. 4. The intrathoracic pressure decreases. 5. The anteroposterior diameter decreases.

1, 3, 4 Rationale: During inspiration, the contraction of the bell-shaped diaphragm causes the chest cavity to descend and flatten. Contractions of the intercostal muscles during inspiration lift the sternum and elevate the ribs, making them more horizontal. Inspiration increases the size of the thoracic cavity and decreases the intrathoracic pressure. Elastic recoil property acts during expiration, not inspiration. The anteroposterior diameter decreases during expiration, not inspiration.

A nursing instructor is describing the pleurae to a class of nursing students. Which statements should the nursing instructor include? 1. The pleurae are thin, slippery, serous membranes. 2. The parietal pleura lines the outside of the lungs. 3. The pleural cavity normally has negative pressure. 4. The pleura lies between the lungs and the chest wall. 5. The visceral pleura lines the inside of the chest wall.

1, 3, 4 Rationale: The pleurae are thin, slippery, serous membranes that form an envelope between the lungs and the chest wall. The pleural cavity is a space which may be filled only with a few milliliters of lubricating fluid that allow the lungs to slide smoothly and noiselessly up and down during normal respiration. The pleural cavity normally has a negative pressure, or vacuum, which holds the lungs tightly against the chest wall. In abnormal conditions, it may be filled with air or fluids that compromise lung expansion. The parietal pleura lines the inside of the chest wall and the diaphragm, whereas the visceral pleura lines the outside of the lungs.

The student nurse is listing the characteristics of normal breath sounds. Which characteristics of normal breath sounds should the student nurse include? (select all that apply) 1. Amplitude 2. Depth 3. Pitch 4. Quality 5. Pressure

1, 3, 4, Rationale: Breath sounds originate in the large airways where the air velocity and turbulence induce vibrations in the airway walls. These vibrations are then transmitted through the lung tissue and the thoracic wall to the surface, where they may be heard readily with the aid of a stethoscope. The characteristics of normal breath sounds are amplitude, pitch, and quality. Amplitude is the size of the vibration, and this determines how loud the sound is. Pitch is the distinctive quality of the sound, which is dependent primarily on the frequency of the sound waves produced by its source. Sound quality is typically an assessment of the accuracy of the audio output. Quality can be measured objectively or subjectively. Depth and pressure are not considered to be characteristics of the normal breath sound.

Which actions should the nurse take when doing a 6-minute walk test (6 MWT) with a patient? 1. Put a pulse oximeter on the patient's finger. 2. Ask the person to walk as fast as possible. 3. Remind the patient not to stop for a rest. 4. Conduct the test in a flat-surfaced corridor. 5. Stop if oxygen saturation is less than 85%.

1, 4, 5 Rationale: The 6 MWT is a safe, simple, inexpensive, clinical measure of functional status in aging adults. The nurse uses a pulse oximeter on the patient's finger to monitor the oxygen saturation. The nurse should do the test on a flat-surfaced corridor with controlled environment. The test must be stopped if the patient's oxygen saturation drops below 85% or if extreme breathlessness occurs. The nurse must ask the patient to set his or her own pace to cover as much ground in 6 minutes. The patient can be assured that it is fine to slow down or stop for rest at any time.

Which observations would the nurse expect in a patient with chronic obstruction pulmonary disease (COPD)? 1. The neck muscles appear to be hypertrophied from overwork. 2. The spinous processes appear as if they are in a straight line. 3. There are no major changes in the color of the patient's skin. 4. The patient leans forward with the arms against the knees. 5. The anteroposterior and transverse diameter are both equal.

1, 4, 5 Rationale: The neck muscles are hypertrophied in COPD from aiding in harder work due to forced respirations across the obstructed airways. The patient has difficulty breathing in the upright position and prefers to sit in the tripod position: the patient leans forward with the arms braced against the knees, chair, or bed. This gives the necessary leverage so that the abdominal, intercostal, and neck muscles can aid in expansion. The patient has a barrel chest with an equal anteroposterior and transverse diameter. This occurs from the hyperinflation of the lungs. A straight spinous process and absence of change in the patient's skin color are normal findings.

How many thoracic vertebrae are present in the human body? 1. 5 2. 6 3. 7 4. 12

12 Rationale: In vertebrates, thoracic vertebrae are present in the middle segment of the vertebral column, between the cervical vertebrae and the lumbar vertebrae. There are 12 thoracic vertebrae present in the human body. The sizes of thoracic vertebrae are between those of the cervical and the lumbar vertebrae. There are 7 cervical, 5 lumbar, and 6 sacrococcygeal vertebrae.

The nurse is assessing a patient who reports a cough that always occurs in the daytime or early evening but subsides at night. What is the most probable cause for the cough? 1. Acute respiratory infection 2. Exposure to irritants at work 3. Development of postnasal drip 4. Bronchial inflammation of smokers

2 Rationale: A cough that occurs in the afternoon or evening is most likely due to exposure to irritants at work. The cough subsides after work hours and does not resume until the next afternoon while at work. An acute respiratory infection causes a continuous cough throughout the day. A patient with postnasal drip or sinusitis is likely to have a cough at night. A patient with bronchial inflammation due to smoking is likely to have a cough early in the morning.

Which assessment finding will the nurse document for a patient with chronic respiratory disease? 1. The patient has cutaneous angiomas. 2. The patient's distal phalanx is clubbed. 3. The patient appears to be very drowsy. 4. The patient appears restless and anxious.

2 Rationale: Clubbing of the distal phalanx occurs with chronic respiratory disease following the growth of vascular connective tissue. Cutaneous angiomas, or spider nevi, are noted in the patient with liver disease. Cerebral hypoxia may cause excessive drowsiness. It may also cause the patient to be restless, anxious, and irritable.

The nurse is giving a lecture about adventitious sounds to nursing students. Which sound should the nurse compare to the opening of a Velcro fastener? 1. Fine crackles 2. Coarse crackles 3. Pleural friction rub 4. High-pitched wheeze

2 Rationale: Coarse crackles are loud, low-pitched bubbling and gurgling sounds. These sounds start during early inspiration and may be present in expiration. These sound like opening a Velcro fastener. Fine crackles are discontinuous, high-pitched, short crackling and popping sounds heard during inspiration. These sounds are not cleared by coughing. This sound can be simulated by rolling strands of hair between the fingers. A pleural friction rub is a very superficial sound that is both coarse and low pitched. It has a grating quality, as if two pieces of leather are being rubbed together. High-pitched wheezing is a musical squeaking sound that sounds polyphonic.

While assessing the tactile fremitus of the patient, the nurse learns that the fremitus is decreased. Which disorder may be diagnosed in the patient? 1. Bronchitis 2. Pleural effusion 3. Lobar pneumonia 4. Pulmonary infarction

2 Rationale: Decreased fremitus occurs when the bronchus of the patient is obstructed. Any barrier that comes between the sound and the palpating hand of the nurse will decrease the fremitus. When there is air outside the lung in the chest cavity, it prevents lung expansion and decreases the tactile fremitus. Pleural effusion, thickening pneumothorax, or emphysema may be responsible for this. During bronchitis and lobar pneumonia, tactile fremitus is normal and is not decreased. In case of pulmonary infarction, fremitus is increased and is not decreased.

During an assessment, the nurse palpates rhonchal fremitus in a patient. Which condition may need to be further investigated? 1. Pneumothorax 2. Thick bronchial secretions 3. Inflammation of the pleura 4. Consolidation of lung tissue

2 Rationale: Fremitus is a palpable vibration. When the patient is asked to say something, the sounds generated from the larynx are transmitted through the patent bronchi and the lung parenchyma to the chest wall, and can be felt as vibrations. Rhonchal fremitus is found when bronchial secretions are thick. A pneumothorax may result in decreased fremitus. Inflammation of the pleura may cause pleural friction fremitus. Consolidation of lung tissues may cause increased fremitus.

The nurse is assessing the lungs of the patient on the anterior side of the chest. Where would the nurse find the highest point of the lung? 1. It is found up to the seventh cervical vertebra. 2. It is found up to 3 to 4 cm above the clavicle. 3. It is found up to the twelfth thoracic vertebra. 4. It is found up to the sixth rib in the midclavicular line.

2 Rationale: In the anterior chest, the apex or highest point of the lung tissue is 3 to 4 cm above the clavicles. The clavicle, commonly known as the collarbone, is located between the sternum and the scapula. Posteriorly, the location of the seventh cervical vertebra marks the apex of the lung tissue. The base, or the lower border of the lung, rests on the diaphragm at about the sixth rib in the midclavicular line. Deep inspiration expands the lungs, and the lower border of the lungs drops up to the twelfth thoracic vertebra.

How much movement of the chest should normally occur during deep inspiration in an average adult? 1. 1 to 2 cm 2. 3 to 5 cm 3. 7 to 8 cm 4. Less than 1 cm

2 Rationale: In the case of an average adult, during deep inspiration, the diaphragmatic excursion should be equal bilaterally and measure about 3 to 5 cm. This movement may be up to 7 to 8 cm in well-conditioned people. In patients who have chronic obstructive pulmonary disease, this movement is 1 to 2 cm. The breathing function will not work if the movement is less than 1 cm.

The nurse is caring for a child with acute epiglottitis. The child has a high-pitched, monophonic, inspiratory crowing sound. What term should the nurse use to document this finding? 1. Crackles 2. Stridor 3. Coarse rales 4. Sonorous rhonchi

2 Rationale: Stridor is a continuous high-pitched, monophonic, inspiratory crowing sound. The sound originates in the larynx or trachea from an upper airway obstruction due to swollen and inflamed tissues. The sound is louder in the neck than over the chest wall. Crackles are discontinuous, high-pitched, short crackling or popping sounds heard during inspiration. They are not cleared by coughing and are caused by fluid in the lungs. Coarse rales are loud, low-pitched, bubbling, and gurgling sounds that start in early inspiration and are caused by pulmonary congestion. Sonorous rhonchi are low-pitched, monophonic, single note, musical snoring and moaning sounds. They are heard throughout the cycle, but are more prominent on expiration. They may be cleared by coughing.

Which statement describes the structure of the lungs? 1. "The lungs contain approximately 300 alveoli." 2. "The right lung is shorter and wider than the left lung." 3. "The trachea bifurcates at the level of T10 posteriorly." 4. "The right lung has two lobes, and the left lung has three lobes."

2 Rationale: The lungs are paired, but are not symmetric structures. The right lung is shorter than the left lung because of the liver present below it. The right lung is wider because the heart bulges to the left. The right lung has three lobes, whereas the left lung has two lobes. The trachea lies anterior to the esophagus. It begins at the level of the cricoid cartilage in the neck and bifurcates just below the sternal angle into the right and the left main bronchi. Each lung contains millions of alveoli.

What should the nurse expect to assess when auscultating the lung sounds of a patient with heart failure? 1. Occasional wheezing 2. Crackles in the lung bases 3. Crackles over upper lobes 4. Bilateral expiratory wheezing

2 Rationale: The nurse is likely to hear crackles at the lung bases. Occasional wheezing may be identified while auscultating the patient with emphysema. Crackles over the upper lobes are heard in the patient with tuberculosis. Bilateral wheezing may heard in the patient with asthma.

What assessment finding will the nurse document in a patient with pneumonia? 1. A smooth chest expansion 2. A lag in the chest expansion 3. A palpable grating sensation 4. A slight inspiratory variation

2 Rationale: The nurse should note a lag in the chest expansion in a patient with pneumonia. Normally, the chest expansion should be smooth, with the thumbs moving apart symmetrically. The nurse is likely to find a palpable grating sensation with breathing in a patient who has pleural friction fremitus. The patient with emphysema is likely to have an abnormally wide costal angle with slight inspiratory variation.

Which structure separates a patient's thoracic cavity from the abdomen? 1. Sternum 2. Diaphragm 3. Manubrium 4. Xiphoid process

2 Rationale: The thoracic cage is defined by the sternum, ribs, the 12 thoracic vertebrae, and the diaphragm. The diaphragm is a musculotendinous septum that separates the thoracic cavity from the abdomen, and it makes up the floor of the thoracic cage. The manubrium and the xiphoid process are both parts of the sternum, which runs down the center of the ribcage. None of these structures separate the thoracic cavity from the abdomen.

Which structures will the nurse assess when looking at the mediastinum? 1. Lungs 2. Heart 3. Trachea 4. Esophagus 5. Pleural cavities

2, 3, 4 Rationale: The mediastinum is in the middle section of the thoracic cavity. The nurse, while assessing the mediastinum, will actually be assessing the heart, trachea, and the esophagus along with the great vessels. The lungs are contained in the right and left pleural cavities on either side of the mediastinum and are not examined with the mediastinum.

What changes occur in the respiratory system during pregnancy that the nurse would tell a pregnant patient about? 1. The chest cage ligaments tighten and restrict full expansion. 2. The total circumference of the chest cage increases by 6 cm. 3. There is a decrease in the vertical diameter of the thoracic cage. 4. The patient has an increased awareness of the need to breathe. 5. The elevation of the diaphragm leads to a decrease in the tidal volume.

2, 3, 4 Rationale: The total circumference of the chest cage increases by 6 cm. The transverse diameter of the chest cage increases by 2 cm and the costal angle widens. Although the diaphragm is elevated, it is not fixed. The enlarging uterus elevates the diaphragm by 4 cm, leading to a decrease in the vertical diameter of the thoracic cage. Physiologic dyspnea may occur in early pregnancy, leading to an increased awareness of the need to breathe. An increase in estrogen levels during pregnancy relaxes the chest cage ligaments, allowing the chest cage to increase in the horizontal diameter. Although the diaphragm is elevated, it moves with breathing even more during pregnancy. This movement results in a 40% increase in tidal volume.

What causes an increased risk for postoperative atelectasis in an elderly patient? 1. Closure of a number of airways 2. Decrease in the ability to cough 3. Loss of protective airway reflexes 4. Decrease in the residual air volume 5. Increase in the amount of secretions

2, 3, 5 Rationale: Histologic changes increase the elderly patient's risk for postoperative pulmonary complications. The costal cartilages become calcified and respiratory muscle strength declines, leading to a decrease in the ability to cough. The loss of protective airway reflexes leads to the inability of clearing the increased amount of secretions. The patient has a greater risk for postoperative atelectasis and infection from a decreased ability to cough, a loss of protective airway reflexes, and increased secretions. Aging causes a number of airways to close; as a result, the lung bases are less ventilated, leading to an increased risk for dyspnea, not atelectasis. The closure of the airways also leads to an increase in the residual air volume, or the amount of air remaining in the lungs, even after the most forceful expiration.

Which assessment findings should the nurse identify with a barrel chest? 1. The thorax is symmetrical in the elliptical shape. 2. The chest appears as if held in continuous inspiration. 3. The ribs appear to be horizontal in relation to the spine. 4. The scapulae are placed symmetrically in each hemithorax. 5. The anteroposterior diameter is equal to the transverse diameter.

2, 3, 5 Rationale: The barrel chest appears as if it is held in continuous inspiration. In this position, the ribs are horizontal in relation to the spine. On the other hand, the ribs in a normal chest slope downwards at an angle of 45 degrees in relation to the spine. In the barrel chest, the anteroposterior diameter and the transverse diameter are equal. Normally, the anteroposterior diameter is less than the transverse diameter. The thorax is usually symmetrical in the elliptical shape and is not specific to the barrel chest. The scapulae are normally placed symmetrically in each hemithorax. These findings are not specific with barrel chest.

While assessing a patient, the nurse hears a cracking or grating sound on auscultation. What abnormality is suspected in the patient? 1. Wheezes 2. Crackles 3. Friction rub 4. Atelectasis

3 Rationale: Palpable friction rub is produced when inflammation of the parietal or visceral pleura causes a decrease in the normal lubricating fluid. Then, the opposing surfaces make a coarse grating sound when rubbed together during breathing. Wheezes are high-pitched, musical squeaking sounds that sound polyphonic and predominate in expiration, but may occur in both expiration and inspiration. Crackles are discontinuous, high-pitched, short popping sounds heard during inspiration that are not cleared by coughing. Atelectasis is defined as the collapse or closure of the lungs, resulting in reduced or absent gas exchange.

A patient presents with Biot's respiration. Which finding will the nurse expect? 1. Breathing rate of less than 10 per minute 2. Gradual wax-and-wane pattern of respiration 3. Normal breathing interrupted by apnea 4. Normal inspiration followed by prolonged expiration

3 Rationale: The breathing pattern in Biot's respiration is irregular. A series of three to four normal respirations is followed by a period of apnea. The length of the cycle is variable and lasts for 10 seconds to 1 minute. It is generally seen in patients with head trauma, brain abscess, heat stroke, spinal meningitis, and encephalitis. In chronic obstructive lung disease, the patient undertakes normal inspiration and prolonged expiration to overcome the increased airway resistance. Gradual wax-and-wane pattern of respiration is seen in the Cheyne-Stokes respiration. A breathing rate of less than 10 per minute occurs in patients who have bradypnea.

Which assessment finding would the nurse associate with mycoplasma pneumonia? 1. Dry cough 2. Barking cough 3. Hacking cough 4. Congested cough

3 Rationale: The patient with mycoplasma pneumonia has a hacking cough. A dry cough may be an early indication of heart failure. A barking cough may be caused by croup. The patient with bronchitis or pneumonia has a congested cough.

The nurse is examining the most prominent spinous process in the vertebral column of a patient who may have spondylosis. Which posterior vertebral landmark is the nurse examining? 1. Cervical 1 2. Lumbar 1 3. Cervical 7 4. Thoracic 12

3 Rationale: The seventh cervical vertebra is the most prominent bony spur protruding at the base of the neck. Sometimes, two bumps are found to be equally prominent. In such a case, the upper one is the seventh cervical vertebra, and the lower one is the first thoracic vertebra. The first cervical, the twelfth thoracic, and the first lumbar vertebra are not the most prominent vertebra in the spinal column.

The nurse is determining diaphragmatic excursion in a patient. Which action should the nurse perform? 1. Observe the chest during the respiratory cycle 2. Palpate the diaphragm during the process of expiration 3. Percuss up and down to locate the diaphragm on inspiration and expiration 4. Auscultate the lung bases during the process of inspiration and expiration

3 Rationale: To determine the diaphragmatic excursion in a patient, the nurse percusses to map out the lower lung border during expiration and inspiration. This estimates the level of the diaphragm separating the lungs from the abdominal viscera. The nurse palpates the anterior chest wall to identify the presence of any tenderness and to detect any possible superficial lumps or masses. Palpation plays a relatively minor role in the examination of the normal chest. The ribs cover the lung; therefore, the palpation does not yield a confirmatory result. The nurse does not need to observe the chest during the respiratory cycle. Auscultation can be quite helpful in trying to pin down the location of the pathologic processes that may be restricted by anatomic boundaries.

The nurse is caring for a patient with small amounts of tissue consolidation in the lungs. What will the nurse hear through the stethoscope when the patient whispers a phrase? 1. The voice is transmitted clearly into the stethoscope. 2. The voice will be muffled, faint, and almost inaudible. 3. The voice can be heard similar to a whisper in the ears. 4. The "eee" sound changes to long bleating "aaa" sound.

3 Rationale: When the patient with small amounts of tissue consolidation in the lungs whispers a phrase, the voice is heard like a whisper in the ears. The condition is said to be whispered pectoriloquy. When the patient has bronchophony, the voice is transmitted very clearly into the stethoscope. This is due to the increased lung density. In a normal lung, the response is faint, muffled, and almost inaudible. If an "eee" sound changes to the long bleating "aaa" sound through the stethoscope, the patient is said to have egophony, or the voice of a goat.

Which breath sounds heard upon auscultation does the nurse consider normal? (select all that apply) 1. Crackles 2. Wheezes 3. Bronchial 4. Vesicular 5. Bronchovesicular

3, 4, 5 Rationale: There are three normal breath sounds. Bronchial breath sounds are high-pitched and loud. Vesicular sounds are low-pitched and soft, and sound more like rustling of the leaves in the wind. Brochovesicular sounds are moderate in pitch and are equal in duration during inspiration and expiration. Crackles and wheezes are abnormal breath sounds. Crackles are discontinuous popping sounds heard during inspiration. Wheezes are continuous musical sounds heard mainly during expiration.

A middle-aged patient comes to the clinic and states, "I can't get my breath when I walk." The nurse notes that the patient has a barrel chest and is using the accessory muscles to breathe. The patient's respiratory rate is 28. On palpation, there is a limited expansion and decreased tactile fremitus. Percussion yields hyperresonant sounds. On auscultation, prolonged expiration, scattered wheezes, and rhonchi are present. Which disorder does the nurse suspect? 1. Atelectasis 2. Pneumonia 3. Emphysema 4. Pleural effusion

3. Rationale: Emphysema is caused by the destruction of the pulmonary connective tissues. This increases airway resistance, especially on expiration, producing a hyperinflated lung and an increase in lung volume. Such patients have a barrel chest and use accessory muscles to breathe. Shortness of breath occurs especially due to physical exertion; therefore, respiratory distress is also commonly observed. Tachypnea or high respiratory rate is also recorded in such patients. Decreased tactile fremitus is found on palpation. Auscultation reveals decreased breath sounds and prolonged expiration. Atelectasis is defined as the collapse or closure of the lung, resulting in reduced or absent gas exchange. Pleural effusion is a condition in which excess fluid builds around the lungs. Pneumonia is an infection affecting the lungs and is caused by microbes. Pneumonia also causes inflammation in the air sacs of the lungs.

The nurse is assessing the respiratory pattern of an adult patient. Which assessment finding should the nurse document as abnormal? 1. Ratio of pulse to respirations is 4:1. 2. Respiratory depth is 500 to 800 mL. 3. Respiratory rate is 24 to 30 per minute. 4. Respiratory pattern appears to be even.

3. Rationale: The normal respiratory rate for an adult is 10 to 20 breaths per minute. An increase in the respiratory rate is normal with fear, fever, or exercise. It may also indicate respiratory insufficiency, pneumonia, alkalosis, pleurisy, and lesions in the pons. Normally, the ratio of pulse to respirations is 4:1. Both the values tend to increase with fear, fever, or exercise. The normal respiratory depth or the air moving in and out with each respiration is 500 to 800 mL. Moreover, the respiratory pattern is also normally even

The nurse is caring for a patient with a regular breathing rate of eight breaths per minute. What is the most likely cause for this condition? 1. Prolonged bed rest 2. Splinting of the chest 3. Overdose of stimulants 4. Drug-induced depression

4 Rationale: Bradypnea, or slow breathing, is the regular breathing rate of less than 10 breaths per minute. It may be caused by drug-induced depression of the respiratory center in the medulla. Hypoventilation is a slow, irregular breathing pattern which occurs due to prolonged bed rest or conscious splinting of the chest to avoid respiratory pain. An overdose of stimulants will increase the respiratory rate, not decrease it.

Which finding is a cause for concern after assessing a patient's respirations? 1. The patient does not make any noise while breathing. 2. The chest expands symmetrically with each inspiration. 3. The accessory muscles are not used during respiration. 4. The interspaces appear to be bulging during expiration.

4 Rationale: Bulging of the interspaces during expiration indicates the presence of trapped air. It may be forced expiration associated with emphysema or asthma. Normal, relaxed breathing is effortless, regular, and even, and produces no noise. The chest expands symmetrically with each inspiration. The accessory muscles are normally not used to augment respiratory efforts. Accessory muscles may be used during heavy exercise or with acute airway obstruction and massive atelectasis.

The nurse is caring for an elderly patient. Which finding does the nurse associate with Cheyne-Stokes respiration? 1. The respiration cycle length is variable. 2. The breathing period lasts for 10 seconds. 3. Three to four respirations are followed by apnea. 4. There are periods of apnea in between normal breaths.

4 Rationale: Cheyne-Stokes respirations include periods of apnea in between normal breaths. The breathing periods last from 30 to 45 seconds, with periods of apnea lasting for about 20 seconds. Biot's respiration is similar to Cheyne-Stokes respiration, but the breathing pattern is irregular, with variable respiration cycle length. A series of three to four normal respirations is followed by a period of apnea. The length of the respiration cycle lasts from 10 seconds to 1 minute.

The nurse is assessing the thorax and lungs of an infant. Which assessment finding needs further investigation? 1. The anteroposterior and transverse diameters are equal. 2. The chest circumference is 2 cm smaller than the head. 3. The chest wall is thin, with prominent ribs and xiphoid. 4. The respiration causes marked retraction of the sternum.

4 Rationale: Marked retractions of the sternum and intercostal muscles indicate increased inspiratory efforts and the need to be investigated further. It may indicate atelectasis, pneumonia, asthma, or an acute airway obstruction. Normal findings for an infant include equal anteroposterior and transverse diameters. The newborn's chest circumference is 30 to 36 cm, and is 2 cm smaller than the head circumference. The chest wall is thin with little musculature, while the ribs and the xiphoid are prominent.

The nurse is assessing a patient who coughed up pink, frothy sputum several times during the day. What is the probable cause for this finding? 1. Tuberculosis 2. Viral infection 3. Bacterial infection 4. Pulmonary edema

4 Rationale: Pulmonary edema is likely to cause pink, frothy sputum production. Some sympathomimetic medications also have a side effect of pink-tinged mucus. Rust-colored sputum is associated with tuberculosis and pneumococcal pneumonia. Viral infections, colds, and bronchitis are likely to cause white or clear mucoid sputum. Yellow or green-colored sputum is associated with bacterial infections.

The nurse starts to count the ribs of the patient from the angle of Louis. Which statement precisely describes the "angle of Louis"? 1. It is continuous with the first rib. 2. It marks the top edge of the sternum. 3. It is also known as the suprasternal notch. 4. It is the articulation of the manubrium and the body of the sternum.

4 Rationale: The angle of Louis is the articulation of the manubrium and the body of the sternum. It is a useful place to start counting the ribs. The angle of Louis helps the nurse localize a respiratory finding horizontally. It is a palpable ridge between the manubrium and the body of the sternum, and it does not mark the top edge of the sternum. The angle of Louis is also called the sternal angle, not the suprasternal notch. It is continuous with the second rib.

What is the function of the goblet cells of the lungs? 1. To enable the exchange of gases 2. To sweep away particulate matter 3. To provide space for gas exchange 4. To entrap small particulate matter

4 Rationale: The bronchial tree protects alveoli from small particulate matter that comes with inhaled air. The bronchi are lined with goblet cells, whose primary function is to secrete mucus that entraps particulate matter. Cilia, on the other hand, are also structures in the bronchi but their primary function is to sweep particulate matter up and away so it can be swallowed or expelled through coughing. Gaseous exchange occurs across the respiratory membrane in the alveolar duct and the alveoli, but does not involve the goblet cells. The alveoli are clustered like grapes around each alveolar duct. This creates millions of interalveolar septa (walls) that increase the space available for gas exchange.

Which part of the lungs is assessed on the posterior chest? 1. Most of the upper lobes 2. The right middle lobe 3. The left middle lobe 4. All parts of the lower lobes

4 Rationale: The entire lower lobe can be assessed on the posterior chest. The upper lobes occupy a small band of tissue from their apices at T1 down to T3 or T4. The right middle lobe does not project onto the posterior chest at all, and the left lung does not have a middle lobe. The lower lobes begin at T3 or T4 and their inferior border reaches down to the level of T10 on expiration and T12 on inspiration.

How does the nurse assess for tactile fremitus in a patient? 1. By placing the fingertips on the sides of the neck 2. By placing the thumb on the spinous process of the patient 3. By placing warmed hands sideways on the posterolateral chest wall 4. By placing the palmar base of one hand to touch the patient's chest

4 Rationale: The nurse uses either the palmar base of the fingers or the ulnar edge of one hand to touch the patient's chest. The patient is asked to repeat resonant phrases such as "ninety-nine" or "blue moon." These phrases generate strong vibrations. The nurse can confirm symmetric chest expansion by placing the warmed hands sideways on the posterolateral chest wall with the thumbs pointing together at the thoracic ninth or tenth vertebra. The nurse places the thumb on the spinous process of the patient to assess the posterior chest. To assess the lymph nodes, the nurse places the fingertips on the sides of the neck of the patient.

What does the term hypercapnia indicate about a patient's respiratory status? 1. Beginning of rapid, deep breathing 2. Presence of slow, shallow breathing 3. Decreased oxygen level in the blood 4. Increased carbon dioxide in the blood

4 Rationale: Respiration helps maintain the pH of the blood by supplying oxygen to the blood and eliminating excess carbon dioxide. Hypercapnia is the term used to describe an increase in the carbon dioxide levels in the blood, and this is the normal stimulus for breathing. Hyperventilation is the presence of rapid, deep breathing in an individual that causes the carbon dioxide to be blown off. On the other hand, hypoventilation causes carbon dioxide to build up in the blood. A decrease in oxygen in the blood is referred to as hypoxemia. Hypoxemia also increases the respiration, but it is less effective than hypercapnia.

_____________ are loud, low-pitched, bubbling, and gurgling sounds that start in early inspiration and are caused by pulmonary congestion.

Coarse rales

_________ occurs when air escapes from the lung and enters the subcutaneous tissue after open thoracic surgery. It is a coarse, crackling sensation palpable over the skin surface.

Crepitus

_________ is caused by the destruction of the pulmonary connective tissues. This increases airway resistance, especially on expiration, producing a hyperinflated lung and an increase in lung volume. Such patients have a barrel chest and use accessory muscles to breathe. Shortness of breath occurs especially due to physical exertion; therefore, respiratory distress is also commonly observed

Emphysema

Fremtius

Fremitus refers to vibratory tremors that can be felt through the chest by palpation

___________ is a condition in which excess fluid builds around the lungs.

Pleural effusion

_____________ is an infection affecting the lungs and is caused by microbes. It also causes inflammation in the air sacs of the lungs.

Pneumonia

In ______________, the patient is asked to repeat "ninety-nine." Through the stethoscope, the words are more distinct than normal, and the sounds are close to the ears of the nurse. This occurs when the pathology increases the lung density.

bronchophony

The body does not require

carbon dioxide.

The patient with bronchitis or pneumonia has a

congested cough.

A barking cough may be caused by

croup.

A _____________ used to be known as rhonchi; the sounds produced have a snoring and gurgling quality.

sonorous wheeze

What should the nurse document as a normal finding when auscultating a toddler's chest for breath sounds? 1.Crackles that are auscultated only in the lower lung fields 2. Persistent fine crackles that are scattered all over the chest 3. Persistent peristaltic sounds with diminished breath sounds 4. Bronchovesicular breath sounds in the peripheral lung fields

4 Rationale: In the normal toddler, auscultation reveals bronchovesicular breath sounds. The child has thin chest walls with underdeveloped musculature, which causes harsher and louder breath sounds. The toddler with heart failure is likely to have crackles only in lower lung fields. Persistent fine crackles that are scattered over the chest occur with pneumonia, bronchiolitis, or atelectasis. Persistent peristaltic sounds with diminished breath sounds on the same side may indicate diaphragmatic hernia.

A college student comes to the emergency room with complaints of a sudden, sharp pain on the right side, and shortness of breath. The right side of the chest is not moving with inspiration. The patient's trachea is deviated toward the left; there is no tactile fremitus on the right. The nurse hears hyperresonant percussion sounds on the right and resonant sounds on the left. There are no breath sounds heard on the right. Which disorder does the nurse suspect? 1. Asthma 2. Atelectasis 3. Pneumonia 4. ,Pneumothorax

4. Pneumothorax is a condition in which free air in the pleural space causes partial or complete lung collapse. In pneumothorax, unequal chest expansion is seen with decreased tactile fremitus. The trachea shifts to the unaffected side. Breath sounds are decreased or absent, and percussion reveals hyperresonance. Atelectasis is defined as the collapse or closure of the lung resulting in reduced or absent gas exchange. Pneumonia is an infection in either one or both the lungs and is caused by microbes. Pneumonia causes inflammation in the air sacs of the lungs. Asthma is an allergic hypersensitivity characterized by bronchospasms and inflammation, edema in the walls of the bronchioles, and secretion of highly viscous mucus into the airways.

__________ is defined as the collapse or closure of the lung, resulting in reduced or absent gas exchange.

Atelectasis

A dry cough may be an early indication of _________

heart failure.