PREP-U Chapter 19: (COMBINED) Assessing Thorax and Lungs
A nurse is auscultating the voice sounds of a client with consolidation in his left lower lobe of his lung due to tumor. Which of the following findings should the nurse expect on performing pectoriloquy?
"1-2-3" is heard clearly. Explanation: To perform whispered pectoriloquy, the nurse asks the client to whisper the phrase "one, two, three" while she auscultates the chest wall. Over areas of consolidation or compression, such as may occur with tumor, the sound is transmitted clearly and distinctly. In such areas, it sounds as if the client is whispering directly into the stethoscope. 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 phrase "Ninety-nine."
A client presents to the health care clinic and reports a recent onset of a persistent cough. The client denies any shortness of breath, change in activity level, or other findings of an acute upper respiratory tract illness. What question by the nurse is most appropriate to further assess the cause for the cough?
"Are you taking any medications on a regular basis?" Explanation: A persistent cough without any other respiratory symptoms could be related to new medications, especially beta blockers or angiotensin converting enzyme (ACE) inhibitors, which are prescribed for hypertension. A change in diet and exercise are healthy behaviors that would not cause a persistent cough. Stress often causes shortness of breath.
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 Explanation: 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.
Which ribs are considered "floating ribs"?
11th and 12th Explanation: Note that the costal cartilages of the first seven ribs articulate with the sternum; the cartilages of the 8th, 9th, and 10th ribs articulate with the costal cartilages just above them. The 11th and 12th ribs, the "floating ribs," have no anterior attachments. The cartilaginous tip of the 11th rib usually can be felt laterally, and the 12th rib may be felt posteriorly. On palpation, costal cartilages and ribs feel identical.
A hospitalized client experiences respiratory distress. The nurse should include which most appropriate client outcome in the plan of care?
Airway patent, breathing quiet, denies dyspnea Explanation: 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.
While inspecting the thorax, the nurse views it from posterior and lateral positions to assess which of the following?
Anteroposterior to lateral diameter Explanation: An important component of chest inspection is assessment of the anteroposterior diameter versus the transverse diameter. This is achieved by viewing the client from the back and side. Costochondral inflammation and tracheal position are not assessed in this way, and assessment of the cervical spine is not a central goal of thoracic inspection.
The nurse is assessing a client's readiness to quit smoking. Place in order the steps in which the nurse will conduct this assessment.
Ask about tobacco use Advise to quit Assess willingness to quit Assist to quit Arrange follow-up Explanation: The 5 A's framework is process used to assess client's readiness to quit smoking and is conducted in the following order: ask about tobacco use, advise to quit, assess willingness to quit, assist to quit, and arrange follow-up.
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?
Asthma Explanation: 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?
Bacterial infection Explanation: 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?
Bases Explanation: 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.
The nurse is preparing to percuss a client's anterior chest area. Which approach will the nurse use for this assessment?
Begin above the right clavicle and percuss each section comparing the right chest with the left chest. Explanation: When percussing a client's anterior chest, the nurse should begin above the level of the clavicles to assess the lung apex. The nurse should assess the right lung area and then the left. The nurse should proceed in a methodical manner and assess each lung area, comparing right to left. The nurse should not percuss all areas on the right side of the chest before assessing the left chest. The nurse should not percuss all areas on the left side of the chest before assessing the right chest. The nurse should not complete the assessment of the left chest and then reverse the process, assessing upward from the liver.
A nurse cares for a client admitted after falling off a ladder onto a concrete floor. The client is not arousable and pupils are fixed and dilated. When performing a respiratory assessment, the nurse recognizes which breathing pattern as normal for clients with brain damage?
Biot's Explanation: In people with irritation or brain damage, the respiratory pattern will be irregular and characterized by varying depth and rate followed by periods of apnea, which is known as Biot's respiration. Cheyne-Stokes is a regular pattern characterized by alternating periods of deep, rapid breathing followed by periods of apnea. Retractive is not an observable pattern of respirations. Kussmaul is seen in clients with diabetic ketoacidosis and are characterized by deep but rapid respirations similar to hyperventilation.
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 Explanation: 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 type of breath sounds should a nurse anticipate on auscultation of the right lower lobe in a client with right lower lobe pneumonia?
Bronchial Explanation: Bronchial sounds are normally heard over the main bronchi. The consolidation of the lung due to right lower lobe pneumonia may carry the bronchial sounds to the peripheral lung area. Vesicular sounds are heard from the bronchioles and lobes. Bronchovesicular lung sounds are normally heard over the main bronchi. Diminished breath sounds occur if the pneumonia has caused severe damage to the lung tissue.
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.
Bronchial Explanation: 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.
Which of the following statements relating to assessment of the lungs and thorax is most accurate?
Bronchitis is characterized by excess mucus production and chronic cough. Explanation: 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.
The nurse is performing the technique shown. What is the nurse assessing?
Chest expansion Explanation: 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
What type of respiratory pattern would the nurse consider normal in a client with severe heart failure?
Cheyne-Stokes Explanation: Cheyne-Stokes respirations, regular respiratory pattern alternating with periods of deep, rapid breathing followed by periods of apnea, may result from severe heart failure. Biot's respirations (irregular pattern of varied depth and rate followed by periods of apnea) may be seen with severe brain damage or meningitis. Bradypnea is a rate less than 10/min and can be associated with medication-induced depression of the respiratory center, diabetic coma, or neurologic damage. Kussmaul respirations are associated with diabetic ketoacidosis.
A client experiences increasing difficulty taking in a deep breath. For which health problem should the nurse focus when assessing this client?
Chronic obstructive lung disease Explanation: The client with COPD may describe the dyspnea as not being able to "breathe or take a deep breath." Although dyspnea is associated with anxiety, pulmonary embolism, and congestive heart failure, the shortness of breath is not described as the inability to take in a deep breath.
Upon inspection of a client's chest, a nurse observes an increase in the ratio of anteroposterior to transverse diameter. The nurse recognizes this as a finding in which disease process?
Chronic obstructive pulmonary disease Explanation: 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.
A 62-year-old construction worker presents to the clinic reporting almost a chronic cough and occasional shortness of breath that have lasted for almost 1 year. Although symptoms have occasionally worsened with a cold, they have stayed about the same. The cough has occasional mucus drainage but never any blood. He denies any chest pain. He has had no weight gain, weight loss, fever, or night sweats. His past medical history is significant for high blood pressure and arthritis. He has smoked two packs a day for the past 45 years. He drinks occasionally but denies any illegal drug use. He is married with two children. He denies any foreign travel. His father died of a heart attack and his mother died of Alzheimer's disease. Examination reveals a man looking slightly older than his stated age. His blood pressure is 130/80 and his pulse is 88. He is breathing comfortably with respirations of 12. His head, eyes, ears, nose, and throat examinations are unremarkable. His cardiac examination is normal. On examination of his chest, the diameter seems enlarged. Breath sounds are decreased throughout all lobes. Rhonchi are heard over all lung fields. There is no area of dullness and no increased or decreased fremitus. What thorax or lung disorder is most likely causing his symptoms?
Chronic obstructive pulmonary disease (COPD) Explanation: This disorder is insidious in onset and generally affects the older population with a smoking history. The diameter of the chest is often enlarged like a barrel. Percussing the chest elicits hyperresonance; during auscultation there is often distant breath sounds. Coarse breath sounds of rhonchi are also often heard. It is important to quantify this client's exercise capacity because it may affect his employment and also allows examiners to follow the progression of his disease. Clinicians must offer smoking cessation as an option.
What associated symptoms might a client with a history of chronic bronchitis have? (Mark all that apply.)
Chronic productive cough Recurrent respiratory infections Wheezing Explanation: Associated symptoms of chronic bronchitis include chronic productive cough and recurrent respiratory infections; wheezing may also develop.
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?
Coarse crackles Explanation: 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.
During the lung assessment for a client with pneumonia, the nurse auscultates low-pitched, bubbling, moist sounds that persist from early inspiration to early expiration. How should the nurse document these sounds?
Coarse crackles Explanation: Low-pitched bubbling, moist sounds that persists from early inspiration to early expiration and sounds like softly separating Velcro should be documented as coarse crackles. These sounds are produced when inhaled air comes into contact with secretions in the large bronchi and trachea. Pleural friction rub is low-pitched, dry, grating sound that is superficial and occurs during both inspiration and expiration. Sonorous wheezes are low-pitched snoring or moaning sounds that may be heard primarily during expiration but may be heard throughout the respiratory cycle. Sibilant wheezes are high-pitched musical sounds heard primarily during expiration but may also be heard on inspiration.
During the assessment of a client with a pneumothorax, what change should the nurse anticipate when auscultating for fremitus?
Decreased Explanation: 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.
What replaces resonance when fluid or solid tissue replaces air-containing lung or occupies the pleural space?
Dullness Explanation: 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 Explanation: 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.
The client has been admitted through the emergency department with chronic bronchitis, has elevated CO2 levels, and has been placed on O2. What priority assessment would the nurse include?
Evaluate changes in respiratory pattern and rate. Explanation: Observe quality and pattern of respiration. Note breathing characteristics as well as rate, rhythm, and depth. Labored and noisy breathing is often seen with severe asthma or chronic bronchitis.
A client with lobar pneumonia would have muffled and indistinct spoken voice sounds.
False
A client comes to the clinic and states, "I have a bad cold and am having trouble breathing." The nurse checks the client's breath sounds and hears bilateral fine crackles at the base. Of what is this finding indicative?
Fluid in the alveoli Explanation: When fluid fills the alveoli, fine crackles may be audible on auscultation. Excessive fluid in the alveoli may lead to airway collapse and decreased breath sounds. Fine crackles are not indicative of fluid in the bronchioles or bronchus or the absence of fluid in the lungs.
Which characteristic feature of the sternum should the nurse observe in a client with the diagnosis of pectus carinatum?
Forward protrusion Explanation: 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 Explanation: 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 Explanation: 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?
Funnel chest (pectus excavatum) Explanation: 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 Explanation: 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?
Heart failure induced orthopnea Explanation: 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 Explanation: 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 client presents to the health care facility with a 2-week history of persistent dry, hacky cough, chest tightness, and shortness of breath with activity. The client admits to a 1-pack-per-day history of cigarette smoking for 20 years. The nurse observes a respiratory rate of 16 breaths per minute, easy and regular. Which nursing diagnosis should the nurse confirm based on this assessment data?
Impaired Gas Exchange Explanation: Impaired Gas Exchange related to chronic lung tissue damage secondary to chronic smoking can be confirmed because of the major criteria of long-standing smoking, shortness of breath, and activity intolerance. The client's cough is dry and hacky, which does not meet the criteria for Ineffective Airway Clearance. There is no data to support the client experiencing a disturbance in sleep or problems with nutrition.
A 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?
In the mediastinum Explanation: 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 Explanation: 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?
Instruct the client to cough forcefully Explanation: 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.
The nurse auscultates the base of the lungs to assess for what reason?
It is where fluid occurs with pulmonary edema. Explanation: Auscultation of the bases is important because it is where fluid occurs with pulmonary edema and the location for fluid accumulation with a pleural effusion. It does not indicate infection or health of the lungs.
Which of the following conditions would produce a hyperresonant percussion note?
Large pneumothorax Explanation: There is a great deal of free air in the chest with a large pneumothorax, which produces a hyperresonant note. The other three conditions produce dullness by dampening the percussion note with fluid.
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?
Look at the image Explanation: Posteriorly, the upper lobes are auscultated above the level of the scapula.
How should a nurse position a client to accurately auscultate the right middle lobe of the lung?
Move the right arm away from the body Explanation: 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.
Auscultation of a 23-year-old client's lungs reveals an audible wheeze. What pathological phenomenon underlies wheezing?
Narrowing or partial obstruction of an airway passage Explanation: The auditory characteristics of wheezing result from narrowing of the lumen of a respiratory passage. Fluid in the alveoli results in crackles, and complete obstruction causes an absence of breath sounds. Decreased lung compliance compromises ventilation but does not necessarily result in wheezes.
A nurse observes a client sitting in the tripod position. What is an appropriate action by the nurse in response to this observation?
Observe for the use of accessory muscles Explanation: The tripod position is often assumed by the client with chronic obstructive pulmonary disease (COPD) in order to help elevate the diaphragm during inspiration. This is often accompanied by the use of accessory muscles of the neck. Crackles are present in pneumonia or fluid in the lungs. Tactile fremitus helps to assess for the presence of a consolidation such as pleural effusion or pneumonia. Diaphragmatic excursion assesses the movement of the diaphragm.
An elderly client reports a feeling of dyspnea with normal activities of daily living. What is an appropriate action by the nurse?
Observe the client's respiratory rate and pattern Explanation: 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 deep inspiration and expiration through the open mouth Explanation: Lung auscultation is performed for one full breath over symmetrical lung fields. The client should be encouraged to breathe deeply through an open mouth.
A client who just underwent hip replacement surgery reports pain at a 10 on a scale of 0 to 10 and receives 4 mg of morphine. A nurse on the orthopedic unit enters the client's room and finds that the client has a respiratory rate of 7 breaths/min. The client is groggy and hard to arouse. What could be contributing to the client's findings?
Opiates, which may cause hypoventilation Explanation: Opiates may reduce the ability of the brain to trigger breathing, causing hypoventilation (slow breathing). This scenario does not describe a reaction to anesthesia, and it is not a normal finding following surgery.
The nurse demonstrates appropriate technique when using what part of the hand to assess for fremitus in a client?
Palmar base Explanation: 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 Explanation: 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.
What color of sputum would support the diagnosis of heart failure?
Pink Explanation: Pink sputum is associated with heart failure. White sputum typically is seen with the common cold. Yellow sputum suggests a bacterial infection. Rust-colored sputum is associated with tuberculosis or pneumococcal pneumonia.
Which action by a nurse demonstrates proper technique for assessment of chest expansion?
Place both hands on the posterior chest at T9, press thumbs together, and then ask client to take a deep breath Explanation: The correct technique for assessment of chest expansion is for the examiner to place the hands on the posterior chest wall with thumbs at the level of T9 or T110 and pressing together a small skin fold. Ask the client to take a deep breath and observe the movement of the thumbs. Using the ball of the hand to feel vibration tests for tactile fremitus. Percussion of the posterior chest wall assesses for tone. The use of a stethoscope is auscultation and this technique assesses for adventitious sounds within the lungs.
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 Explanation: Pleurisy can follow inflammation of the parietal pleura. Patients usually describe such pain as sharp or stabbing, worsening with deep breathing or coughing. Pneumonia does not always cause pain on respiration nor does asthma. Rales are an adventitious breath sound, not a respiratory condition.
A 47-year-old receptionist comes to the office with fever, shortness of breath, and a productive cough with golden sputum. She says she had a cold last week and her symptoms have only worsened despite using over-the-counter cold remedies. She denies any weight gain, weight loss, or cardiac or gastrointestinal symptoms. Her past medical history includes type 2 diabetes for 5 years and high cholesterol level. She takes an oral medication for both diseases. She has had no surgeries. She denies tobacco, alcohol, or drug use. Her mother has diabetes and high blood pressure. Her father passed away from colon cancer. Examination reveals a middle-aged woman appearing her stated age. She looks ill and her temperature is elevated at 101 degrees Fahrenheit. Her blood pressure and pulse are unremarkable. Her head, eyes, ears, nose, and throat examination are unremarkable except for edema of the nasal turbinates. On auscultation she has decreased air movement and coarse crackles are heard over the left lower lobe. There is dullness on percussion, increased fremitus during palpation, and egophony and whispered pectoriloquy on auscultation. What disorder of the thorax or lung best describes her symptoms?
Pneumonia Explanation: 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.
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 Explanation: Decreased chest excursion is seen with emphysema. Asymmetrical chest movements may be due to pneumonia, pneumothorax, trauma or atelectasis.
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 Explanation: 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 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?
Pulmonary edema Explanation: 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 posterior lung fields, which of the following findings is expected?
Resonance over all lung fields Explanation: 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.
The spinous process termed the vertebra prominens is in which cervical vertebra?
Seventh. Explanation: The spinous process of the seventh cervical vertebra (C7), also called the vertebra prominens, can be easily felt with the client's neck flexed.
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?
Severe brain damage Explanation: 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?
Sibilant wheezes heard primarily during expiration but may also be heard on inspiration Explanation: 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?
Skin between the ribs moves inward with inspiration. Explanation: 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?
Sound is louder and sounds like "A" Explanation: 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".
When preparing to examine a client's thoracic cage, the nurse would locate which landmark as most helpful in determining where to start?
Sternal angle Explanation: The sternal angle or angle of Louis, the bony ridge that can be palpated at the point where the manubrium articulates with the body of the sternum, is a reference point for examining the thorax. The other options, since each is specific to a particular part of the thoracic area, are not landmarks to use when beginning a thoracic cage assessment .
A high-pitched crowing sound from the upper airway results from tracheal or laryngeal spasm and is called what?
Stridor Explanation: 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 Explanation: 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.
Which observation confirms to the nurse that the client is experiencing a normal inspiration?
The thoracic cavity enlarges. Explanation: 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. Explanation: The brainstem contains the medulla and the pons, which control involuntary respiratory effort. The negative response to stimuli is unrelated to the client's respiratory effort. The client's breathing patterns will change according to cellular demands. The levels of carbon dioxide and oxygen in the blood also will vary based on the client's respiratory efforts as well as interventions used to sustain these efforts.
Which finding during an assessment of a client should alert the nurse to the presence of a persistent atelectasis?
Unequal expansion of the chest Explanation: Unequal expansion of the chest indicates atelectasis or lung collapse. The inhaled air is unable to inflate the diseased lung; therefore, there is an unequal expansion of the chest. Crepitus on palpation can be found in clients with an open thoracic injury or with a tracheostomy. Sunken sternum and adjacent cartilages are seen in funnel chest. Retraction of intercostal spaces occurs in labored breathing.
The nurse is preparing to auscultate the lung sounds of a young adult. Which sound will the nurse expect to hear over most of the client's lungs?
Vesicular Explanation: Vesicular breath sounds are normally heard over most of both lungs. In a young adult, this is the sound that the nurse will most likely hear when auscultating the client's lungs. Bronchovesicular breath sounds are normally heard in the 1st and 2nd intercostal spaces anteriorly and between the scapulas 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.
The clavicles extend from the acromion of the scapula to the part of the sternum termed the
manubrium. Explanation: The clavicles extend from the manubrium to the acromion of the scapula.
The apex of each lung is located at the
area slightly above the clavicle. Explanation: The apex of each lung extends slightly above the clavicle.
The nurse is preparing to auscultate the posterior thorax of an adult female client. The nurse should
ask the client to breathe deeply through her mouth. Explanation: 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.
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?
coarse crackles Explanation: Coarse crackles change or disappear with coughing. Rhonchi are a variation of wheezes but are lower in pitch. They may also disappear with coughing. Wheezes are continuous musical sounds. Fine crackles are soft, high-pitched and change according to body position.
The nurse has assessed the respiratory pattern of an adult client. The nurse determines that the client is exhibiting Kussmaul respirations with hyperventilation. The nurse should contact the client's physician because this type of respiratory pattern usually indicates
diabetic ketoacidosis. Explanation: Kussmaul respirations are rapid, deep, and labored. They are considered a type of hyperventilation associated with diabetic ketoacidosis.
The nurse percusses the lungs of a client with pneumonia. What percussion note would the nurse expect to document?
dullness
Under normal circumstances, the strongest stimulus to breathe is
hypercapnia. Explanation: 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?
hyperresonance Explanation: 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.
While assessing an adult client, the client tells the nurse that she "has had difficulty catching her breath since yesterday." The nurse should assess the client further for signs and symptoms of
infection. Explanation: Sudden onset of dyspnea is associated with viral or bacterial infections.
The client reports severe pain when breathing in deeply. The description suggests to the nurse that the client is experiencing which respiratory condition?
inflammation of the parietal pleura Explanation: 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?
less than 90 degrees Explanation: 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. Reference:
Identify the location where vesicular, bronchovesicular, bronchial, and tracheal lung sounds are heard (in that order).
over most of both lungs between the scapulae over the manubrium over the trachea in the neck
Identify the location where vesicular, bronchovesicular, bronchial, and tracheal lung sounds are heard (in that order). Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left. 1over most of both lungs 2between the scapulae 3over the manubrium 4over the trachea in the neck
over most of both lungs between the scapulae over the manubrium over the trachea in the neck
Which pleural membrane lines the chest cavity?
parietal pleura Explanation: 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.
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." Explanation: 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?
sternocleidomastoids Explanation: 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.
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
tuberculosis. Explanation: Rust-colored sputum is associated with tuberculosis or pneumococcal pneumonia.
