PrepU ch.19 Assessing Lungs and Thorax

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

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

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

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

The nursing instructor teaches students the most accurate location to auscultate the right middle lobe of the lung is where? a.Anterior b.Posterior c.Laterally d.Medially

a. Anterior The right middle lobe is best auscultated using the anterior approach. Only a small portion an be auscultated laterally.

What would the nurse expect to hear when auscultating the lungs of a client diagnosed with pleuritis? a.Friction rub b.Decreased breath sounds c.Sibilant wheeze d.Stridor

a. Friction rub In pleuritis, inflamed pleural surfaces lose their normal lubrication and rub together during breathing. Reduced volume of pleural fluid increases the transmission of lung sounds and leads to a possible friction rub. Decreased breath sounds may indicate an obstruction due to little air moving in and out. Sibilant wheezes are often heard with bronchitis; stridor occurs with severe broncholaryngo spasms, such as croup. Stridor is associated with a loud, high-pitched crowing that is characteristic of epiglottis or other conditions that partially obstruct the upper airway.

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? a.Pleurisy b.Pneumonia c.Asthma d.Rales

a. Pleurisy Pleurisy can follow inflammation of the parietal pleura. Patients usually describe such pain as sharp or stabbing, worsening with deep breathing or coughing. Pneumonia does not always cause pain on respiration nor does asthma. Rales are an adventitious breath sound, not a respiratory condition.

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

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

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

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

The nurse assesses an adult client and observes that the client's breathing pattern is very labored and noisy, with occasional coughing. The nurse should refer the client to a physician for possible... a.chronic bronchitis. b.atelectasis. c.renal failure. d.congestive heart failure.

a. chronic bronchitis. Labored and noisy breathing is often seen with severe asthma or chronic bronchitis.

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

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

An elderly client reports a feeling of dyspnea with normal activities of daily living. What is an appropriate action by the nurse? a.Report this to the health care provider immediately b.Assess for symmetry of chest expansion c.Observe the client's respiratory rate and pattern d.Ask the client how long they have to rest between activities

Observe the client's respiratory rate and pattern It is normal for elderly clients to feel short of breath or dyspneic with activities of daily living due to age related changes of loss of elasticity, fewer functional capillaries, and loss of lung resiliency. Observing chest expansion would be appropriate assessment for a client with a pneumothorax. This finding does not need to be reported to the health care provider unless accompanied by other findings of inadequate oxygenation. Asking the client how long they need to rest between activities will not provide the nurse any objective information to differentiate the problem.

A nurse is receiving report from the night shift about four clients. Which client would the nurse see first? a.A 64-year-old man with COPD who is short of breath and has a respiratory rate of 32 breaths/min. b.A 57-year-old woman who had surgery yesterday for a small bowel obstruction with possible wound dehiscence. c.A 23-year-old woman who had a mountain biking accident in which she suffered a neck fracture and now has numbness and tingling in her right arm. d.A 29-year-old woman with a history of drug abuse and a heart rate of 124 beats/min.

a. A 64-year-old man with COPD who is short of breath and has a respiratory rate of 32 breaths/min. Decreased level of consciousness, respiratory rate above 30 breaths/min, cyanosis, retractions, and use of accessory muscles may indicate hypoxia (a medical emergency). The only scenario in line with these criteria is the man with COPD.

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? a.Bradypnea b.Tachypnea c.Hyperventilation d.Hypoventilation

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

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? a.Dyspnea b.Tachypnea c.Shortness of breath d.Anxiety

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

The nurse is reviewing the client's health history and notes he has pectus excavatum. The nurse would assess the client for what? a.Funnel chest b.Pigeon chest c.Intercostal bulging d.Pectoriloquy

a. Funnel chest Pectus excavatum or funnel chest occurs when the sternum and adjacent cartilages are significantly sunken inward or dented. Pigeon chest or pectus carinatum occurs when the sternum protrudes backward. Intercostal bulging is noted with trapped air. Whispering pectoriloquy is identified when sounds are louder and clearer than the whispered sounds.

A client has a history of emphysema. The nurse percussing the client's chest expects to hear what characteristic sound? a.Hyperresonance b.Dullness c.Resonance d.Tympany

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

A 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? a.Ineffective Airway Clearance b.Risk for Respiratory Infection c.Impaired Gas Exchange d.Ineffective Breathing Pattern

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

The nurse auscultates the base of the lungs to assess for what reason? a.It is where fluid occurs with pulmonary edema. b.It best reflects the health of the lungs. c.It indicates early infection.

a. It is where fluid occurs with pulmonary edema. 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.

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? a.Opiates, which may cause hypoventilation b.Opiates, which may cause hyperventilation c.Anesthesia, from surgery that morning d.Nothing, this is normal following surgery

a. Opiates, which may cause hypoventilation 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.

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

a. There is loss of involuntary respiratory control. The brainstem contains the medulla and the pons, which control involuntary respiratory effort. The negative response to stimuli is unrelated to the client's respiratory effort. The client's breathing patterns will change according to cellular demands. The levels of carbon dioxide and oxygen in the blood also will vary based on the client's respiratory efforts as well as interventions used to sustain these efforts.

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... a.diabetic ketoacidosis. b.central nervous system injury. c.drug overdose. d.congestive heart failure.

a. diabetic ketoacidosis. Kussmaul respirations are rapid, deep, and labored. They are considered a type of hyperventilation associated with diabetic ketoacidosis.x The nurse assesses an adult client's thoracic area and observes a markedly sunken sternum and adjacent cartilages. The nurse should document the client's pectus thorax. pectus excavatum. pectus carinatum. pectus diaphragm.

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

a. dullness Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 19: Assessing Thorax and Lungs, p. 396. Chapter 19: Assessing Thorax and Lungs - Page 396

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... a.repeat the phrase "ninety-nine." b.repeat the letter "E." c.whisper the phrase "one-two-three." d.repeat the letter "A."

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

The nurse documents vesicular lung sounds upon auscultation. The nurse heard what type of sound? a.sound heard throughout inspiration and two thirds of expiration b.inspiratory and expiratory sounds equal in length c.expiratory sounds lasting longer than inspiratory d.short silence between inspiration and expiration

a. sound heard throughout inspiration and two thirds of expiration Chapter 19: Assessing Thorax and Lungs - Page 402

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

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

A nurse auscultates a client's lungs and hears fine crackles. What is an appropriate action by the nurse? a.Listen again with the bell of the stethoscope b.Instruct the client to cough forcefully c.Have the client breathe through the mouth d.Assess for the use of accessory muscles

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

Which characteristic of a cough should alert the nurse to assess the client for other findings of sinusitis? a.Onset upon awakening b.Nighttime when lying down c.Intermittent but worse in evening d.Persistent all day

b. Nighttime when lying down A cough that occurs when lying down at night is due to sinusitis or postnasal drip. Continuous coughs are usually associated with acute infections; whereas those occurring only early in the morning are often associated with chronic bronchial inflammation or smoking. Coughs late in the evening may be the result of exposure to an irritant during the day.

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? a.Tuberculosis b.Pulmonary edema c.Infection d.Atelectasis

b. Pulmonary edema Pink, frothy sputum may indicate pulmonary edema. Tuberculosis sputum may be a rusty color and green sputum may indicate an infection. The client with atelectasis may not be coughing any sputum up.

Which of the following occurs in respiratory distress? a.The client speaks in sentences of 10-20 words. b.Skin between the ribs moves inward with inspiration. c.Neck muscles are relaxed. d.Client torso leans posteriorly.

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

The apex of each lung is located at the... a.level of the diaphragm. b.area slightly above the clavicle. c.level of the sixth rib. d.left oblique fissure.

b. area slightly above the clavicle. The apex of each lung extends slightly above the clavicle.

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

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

The nurse assesses an adult client's thoracic area and observes a markedly sunken sternum and adjacent cartilages. The nurse should document the client's... a.pectus thorax. b.pectus excavatum. c.pectus carinatum. d.pectus diaphragm.

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

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? a."Have you changed your diet within the past few weeks?" b."How much do you exercise during the week?" c."Are you taking any medications on a regular basis?" d."Do you feel that you are under a great deal of stress?'

c. "Are you taking any medications on a regular basis?" 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 spinous process termed the vertebra prominens is in which cervical vertebra? a.Fifth. b.Sixth. c.Seventh. d.Eighth.

c. Seventh. 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 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? a.Spontaneous pneumothorax b.Chronic obstructive pulmonary disease (COPD) c.Asthma d.Pneumonia

c. Asthma Asthma causes shortness of breath and a nocturnal cough. It is often associated with a history of allergies and can be exacerbated by exercise or irritants such as smoke in a bar. On auscultation there can be normal to decreased air movement. Wheezing is heard on expiration and sometimes inspiration. The duration of wheezing in expiration usually correlates with the severity of illness, so it is important to document this length (e.g., wheezes heard halfway through exhalation). In severe asthma, wheezes may not be heard because of the lack of air movement. Paradoxically, these clients may have more wheezes after treatment, which actually indicates an improvement in condition. Peak flow measurements help to discern this.

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? a.Carcinoma of the lungs b.Pneumothorax c.Chronic obstructive pulmonary disease d.Tuberculosis

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

A nurse is auscultating a client's chest for breath sounds. The nurse recognizes that which of the following is the strongest stimulus to breathe? a.Hypoxemia b.Hypoventilation c.Hypercapnia d.Hyperventilation

c. Hypercapnia Under normal circumstances, the strongest stimulus to breathe is an increase of carbon dioxide in the blood (hypercapnia). A decrease in oxygen (hypoxemia) also increases respiration but is less effective than a rise in carbon dioxide levels. Hypoventilation is a breathing pattern marked by a decreased rate, decreased depth, and irregular pattern. Hyperventilation is a breathing pattern marked by increased rate and depth.

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

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

A triage nurse is working in the emergency department of a busy hospital. Four clients have recently been admitted. Patient A has an arrhythmia diagnosed as atrial fibrillation; Patient B is in chronic congestive heart failure; Patient C is assessed and found to have a probable pulmonary embolism; Patient D complains of chest pain relieved by nitroglycerin and rest. Which client would be the nurse's highest priority? a.Patient A b.Patient B c.Patient C d.Patient D

c. Patient C Cardiac emergencies that necessitate rapid assessment and intervention include acute coronary syndromes, acute decompensated heart failure, hypertensive crisis, cardiac tamponade, unstable cardiac arrhythmias, cardiogenic shock, systemic or pulmonary embolism, and aortic dissection.

When percussing the anterior chest for tone, a nurse should anticipate what tone over the majority of the lung fields? a.Hyperresonance b.Dullness c.Resonance d.Tympany

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

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

c. Resonance over all lung fields All lung tissue is expected to be resonant on percussion. Hyperresonance and tympany suggest a hyperinflated lung or pneumothorax. Dullness is expected in structures below the level of the diaphragm, but dullness in the bases of the lungs themselves would be considered pathological.

A nurse is assessing a client with acute asthma. Which adventitious breath sound should the nurse expect to hear in this client? a.Fine crackles occurring late in inspiration b.Course crackles occurring from early inspiration to early expiration c.Sibilant wheezes heard primarily during expiration but may also be heard on inspiration d.Sonorous wheezes heard primarily during expiration but may be heard throughout the respiratory cycle

c. Sibilant wheezes heard primarily during expiration but may also be heard on inspiration Sibilant wheezes are often heard in cases of acute asthma or chronic emphysema. Fine crackles occurring late in inspiration are associated with restrictive diseases such as pneumonia and congestive heart failure. Course crackles that persist from early inspiration to early expiration may indicate pneumonia, pulmonary edema, or pulmonary fibrosis. Sonorous wheezes are often heard in cases of bronchitis or single obstructions and snoring before an episode of sleep apnea.

The staff educator from the hospital's respiratory unit is providing a public educational event. The educator is talking about health promotion activities for people with respiratory diseases or those who are at high risk for respiratory complications. What would the educator include in the presentation? a.Encouraging adequate rest b.Reinforcing the need for a high-calorie diet c.Teaching strategies to reduce complications of existing diagnoses d.Showing participants how to diagnose respiratory problems

c. Teaching strategies to reduce complications of existing diagnoses Health promotion activities focus on preventing disease from developing (primary prevention), screening to identify conditions at an early curable stage (secondary prevention), and reducing complications of existing or established medical diagnoses (tertiary prevention).

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

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

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? a.Emphysema b.Lung cancer c.Sleep apnea d.Bacterial infection

d. 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. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 19: Assessing Thorax and Lungs, p. 386. Chapter 19: Assessing Thorax and Lungs - Page 386

The nurse is preparing to percuss a client's anterior chest area. Which approach will the nurse use for this assessment? a.Begin at the sternal notch and percuss all areas on the right chest then all areas on the left chest. b.Begin at the sternal notch and percuss all areas on the left chest then all areas on the right chest. c.Begin above the left clavicle and percuss all areas on the left chest, then reverse the process and assess the right chest moving upward from the liver. d.Begin above the right clavicle and percuss each section comparing the right chest with the left chest.

d. Begin above the right clavicle and percuss each section comparing the right chest with the left chest. 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.

Which of the following statements relating to assessment of the lungs and thorax is most accurate? a.Hemoptysis is more common in children and adolescents than in older clients. b.Moderate to severe chest pain is associated with a cardiac etiology, while mild to moderate chest pain is most often respiratory in origin. c.Loud and very loud percussion notes denote pathological findings. d.Bronchitis is characterized by excess mucus production and chronic cough.

d. Bronchitis is characterized by excess mucus production and chronic cough. Bronchitis is marked by a chronic, productive cough that results from excess mucus production. Hemoptysis is uncommon in younger clients. It would be simplistic to differentiate cardiac from respiratory chest pain based on severity alone. Similarly, it is inaccurate to characterize all loud percussion sounds as pathological.

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

d. 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. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 19: Assessing Thorax and Lungs, p. 403. Chapter 19: Assessing Thorax and Lungs - Page 403

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

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

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? a.Assess for signs of nonproductive cough. b.Review blood work including RBC and WBC. c.Assess the characteristics of sputum. d.Evaluate changes in respiratory pattern and rate.

d. Evaluate changes in respiratory pattern and rate. 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.

What should be the nurse's initial intervention when adventitious sounds are heard during auscultation of a client's lungs? a.Refer the client for further medical evaluation. b.Auscultate for egophony. c.Perform bronchophony. d.Have the client cough and then listen again.

d. Have the client cough and then listen again. If abnormalities are noted during lung auscultation, the nurse should have the client cough and then listen again, noting any change. Coughing may clear the lungs. If the sounds are still present after coughing, then the nurse would refer the client for further evaluation. Auscultating voice sounds (egophony and bronchophony) would be done as part of any assessment of the thorax.

Auscultation of a 23-year-old client's lungs reveals an audible wheeze. What pathological phenomenon underlies wheezing? a.Fluid in the alveoli b.Blockage of a respiratory passage c.Decreased compliance of the lungs d.Narrowing or partial obstruction of an airway passage

d. Narrowing or partial obstruction of an airway passage 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? a.Auscultate for the presence of crackles b.Palpate for tactile fremitus c.Percuss to determine diaphragmatic excursion d.Observe for the use of accessory muscles

d. Observe for the use of accessory muscles The tripod position is often assumed by the client with chronic obstructive pulmonary disease (COPD) in order to help elevate the diaphragm during inspiration. This is often accompanied by the use of accessory muscles of the neck. Crackles are present in pneumonia or fluid in the lungs. Tactile fremitus helps to assess for the presence of a consolidation such as pleural effusion or pneumonia. Diaphragmatic excursion assesses the movement of the diaphragm.

The nurse obtains a flat sound when percussing the right lower lobe of a client. What does this assessment finding indicate to the nurse? a.Healthy lung tissue b.Gastric air bubble c.Emphysema d.Pleural effusion

d. Pleural effusion When a flat sound is percussed over lung tissue, this is an indication of a pleural effusion. Resonance is the percussion sound of healthy lung tissue. The sound of a gastric air bubble is tympany. Hyperresonance is the percussion sound associated with emphysema.

A 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? a.Spontaneous pneumothorax b.Chronic obstructive pulmonary disease (COPD) c.Asthma d.Pneumonia

d. Pneumonia Pneumonia is usually associated with dyspnea, cough, and fever. On auscultation there can be coarse or fine crackles heard over the affected lobe. Percussion over the affected area is dull, and there is often an increase in fremitus. Egophony and pectoriloquy are heard because of increased sound transmission of high-pitched components of sounds. The multiple air-filled chambers of the alveoli usually filter out these higher frequencies.

A client 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? a.Diabetic ketoacidosis b.Renal failure c.Narcotic overdose d.Severe brain damage

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

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

d. less than 90 degrees The right and left costal margins meeting at the level of the xiphoid process form an angle between them. This angle, commonly referred to as the costal angle, is an important landmark for assessment. It is normally less than 90 degrees but may be increased in instances of long-standing hyperinflation of the lungs, as in emphysema.