PrepU - Chapter 19: Assessing Thorax and 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 surger

A. Opiates, which may cause hypoventilation

Which description of exterior landmarks indicates normal positioning of the lungs? A. Anteriorly, the lower border of the lung crosses the 6th rib at the midclavicular line. B. The anterior baseline of the lungs cross the midaxillary line at the 7th rib. C. Posteriorly, the lower border of the lung lies at the level of T9. D. Posteriorly, the lower border of the lung ascends to the level of T8 during inspiration.

A. Anteriorly, the lower border of the lung crosses the 6th rib at the midclavicular line.

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

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

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

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 nurse notes that a client has the thoracic structure shown. How should the nurse document this finding? A. Barrel chest B. Funnel chest C. Pectus carinatum D. Thoracic kyphoscoliosis

D. Thoracic kyphoscoliosis

During a health history of the respiratory system, a patient reports experiencing a cough for several months. Which questions would the nurse ask for more information about the duration of this symptom? (Select all that apply.) - "Does this occur at a particular time of day?" - "Is it continuous or intermittent?" - "Does it occur at rest or with exercise?: - "Does it wake you at night?" - "Do you cough up mucus or phlegm?"

- "Does this occur at a particular time of day?" - "Is it continuous or intermittent?" - "Does it occur at rest or with exercise?: - "Does it wake you at night?"

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

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

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

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

Which finding during an assessment of a client should alert the nurse to the presence of a persistent atelectasis? A. The presence of crepitus on palpation B. A depressed sternum and cartilages C. Retraction of intercostal spaces D. Unequal expansion of the chest

D. Unequal expansion of the chest

Which action by a nurse demonstrates the proper sequence for auscultation of the lung fields? A. Listen at each site for at least one complete respiratory cycle B. Move from anterior to posterior on the same side C. Instruct the client to breathe in and out rapidly through the mouth D. Use the diaphragm then the bell in each location

A. Listen at each site for at least one complete respiratory cycle

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? A. Coarse crackles B. Pleural friction rubs C. Sonorous wheezes D. Sibilant wheezes

A. Coarse crackles

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

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? A. Fluid in the alveoli B. Fluid in the bronchioles C. Fluid in the bronchus D. No fluid present

A. Fluid in the alveoli

A patient comes to the clinic complaining of waking during the night with sudden shortness of breath. She is diagnosed with paroxysmal nocturnal dyspnea. Before leaving the clinic, the patient asks the nurse what causes paroxysmal nocturnal dyspnea. What would be the nurse's best response? A. Fluid overload from elevation of the legs B. Congestive heart failure C. Cardiac decompensation D. Fluid overload related to renal failure

A. Fluid overload from elevation of the legs

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? A. Pneumothorax B. Atelectasis C. Muscular weakness D. Asthma

A. Pneumothorax

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

A. Stridor

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? A. Suprasternal notch B. Sternal angle C. Acromion of the scapula D. Xiphoid process

A. Suprasternal notch

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.

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

A. a foreign body obstruction

The thin double-layered serous membrane that lines the chest cavity is termed A. parietal pleura. B. pulmonary pleura. C. visceral pleura. D. thoracic pleura.

A. parietal pleura.

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."

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 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.

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

B. Bases

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? A. Fine crackles B. Coarse crackles C. Sibilant wheeze D. Sonorous wheeze

B. Coarse crackles

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

B. Decreased

Which of the following muscles is primarily responsible for thoracic cavity enlargement? A. Scalene B. Diaphragm C. Parasternal D. Sternomastoid

B. Diaphragm

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

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? A. Barrel chest B. Funnel chest (pectus excavatum) C. Pigeon chest (pectus carinatum) D. Thoracic kyphoscoliosis

B. Funnel chest (pectus excavatum)

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

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.

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

B. T4 spinous process

Which statement regarding the location of landmarks is associated with the assessment of the respiratory system? A. The sternal angle is approximately at the same level as the manubrium. B. The inferior tip of the scapula usually lies at the level of the 7th rib. C. The lower end of an endotracheal tube is usually at the level of T2. D. The most protruding vertebral prominens are located at C4.

B. The inferior tip of the scapula usually lies at the level of the 7th rib.

While inspecting the thorax, the nurse views it from posterior and lateral positions to assess which of the following? A. Position of the trachea B. Curvature of the cervical spine C. Anteroposterior to lateral diameter D. Inflammation of the costochondral junction

C. Anteroposterior to lateral diameter

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

When auscultating the lungs, the nurse listens over symmetrical lung fields for which of the following? A. One quiet full inspiration through pursed lips B. Two full breaths every 10 seconds through the nose C. One deep inspiration and expiration through the open mouth D. Two full breaths in through the mouth and out through the nose

C. One deep inspiration and expiration through the open mouth

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

A triage nurse is working in the emergency department of a busy hospital. Four patients 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 patient would be the nurse's highest priority? A. Patient A B. Patient B C. Patient C D. Patient D

C. Patient C

The spinous process termed the vertebra prominens is in which cervical vertebra? A. Fifth. B. Sixth. C. Seventh. D. Eighth.

C. Seventh.

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

The nurse is preparing to percuss a patient'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.

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.

A client experiences increasing difficulty taking in a deep breath. For which health problem should the nurse focus when assessing this client? A. Anxiety B. Pulmonary embolism C. Congestive heart failure D. Chronic obstructive lung disease

D. Chronic obstructive lung disease

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.

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.

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? A. Ineffective Airway Clearance B. Disturbed Sleep Pattern C. Risk for Imbalanced Nutrition D. Impaired Gas Exchange

D. Impaired Gas Exchange

The nurse obtains a flat sound when percussing the right lower lobe of a patient. What does this assessment finding indicate to the nurse? A. Healthy lung tissue B. Gastric air bubble C. Chronic bronchitis D. Pleural effusion

D. Pleural Effusion

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 Farenheit. 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

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.

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 A. pulmonary edema. B. bronchitis. C. asthma. D. tuberculosis.

D. tuberculosis.