Chapter 18: Thorax and Lungs

The nurse is assessing voice sounds during a respiratory assessment. Match the assessment with the correct technique: 1. The normal response is faint, muffled, and almost inaudible when the patient says "one, two, three" in a very soft voice. 2. Ask the person to say "ninety-nine" repeatedly while auscultating the chest wall. Normally, a sound will be heard but the examiner will not be able to distinguish exactly what is being said. 3. Listen to the chest while the patient says a long "ee-ee-ee" sound; hearing a long "aaaaaa" sound may be noted over areas of consolidation.

1. B = Bronchophony 2. E = Egophony 3. W = Whispered pectoriloquy ANS:2,3,1

29. An adult patient with a history of allergies comes to the clinic complaining of wheezing and difficulty in breathing when working in his yard. The assessment findings include the following: tachypnea, use of accessory neck muscles, prolonged expiration, intercostal retractions, decreased breath sounds, and expiratory wheezes. This description is consistent with: 1. asthma. 2. atelectasis. 3. lobar pneumonia. 4. congestive heart failure.

ANS: 1 Asthma is allergic hypersensitivity to certain inhaled particles that produces inflammation and a reaction of bronchospasm, which increases airway resistance, especially during expiration. Increased respiratory rate, use of accessory muscles, retraction of intercostal muscles, prolonged expiration, decreased breath sounds, and expiratory wheezing are all characteristic of asthma.

During auscultation of the lungs, the nurse knows that decreased breath sounds would most likely be heard: 1. when the bronchial tree is obstructed. 2. when adventitious sounds are present. 3. in conjunction with whispered pectoriloquy. 4. in conditions of consolidation, such as pneumonia.

ANS: 1 Decreased or absent breath sounds occur when the bronchial tree is obstructed, in emphysema, and when sound transmission is obstructed as in pleurisy, pneumothorax, or pleural effusion.

During auscultation of breath sounds, the nurse will use the stethoscope correctly, as follows: 1. Listen to at least one full respiration in each location. 2. Listen as the patient inhales and then go to the next site during exhalation. 3. Have the patient breathe in and out rapidly while the nurse listens to the breath sounds. 4. If the patient is modest, listen to sounds over his or her clothing or hospital gown.

ANS: 1 During auscultation of breath sounds with a stethoscope, it is important to listen to one full respiration in each location. During the examination, monitor the breathing and offer times for the person to breathe normally to prevent possibly dizziness.

A 70-year-old patient is being seen in the clinic for severe exacerbation of his heart failure. Which of the following findings is the nurse most likely to observe in this situation? 1. Shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, ankle edema 2. Rasping cough, thick mucoid sputum, wheezing 3. Productive cough, dyspnea, weight loss, anorexia 4. Fever, dry nonproductive cough, bronchial breath sounds

ANS: 1 Heart failure often presents with increased respiratory rate, shortness of breath on exertion, orthopnea, paroxysmal nocturnal dyspnea, nocturia, ankle edema, and pallor in light-skinned individuals.

When assessing tactile fremitus, the nurse recalls that it is normal to feel tactile fremitus most intensely over which location? 1. Between the scapulae 2. Third intercostal space, MCL 3. Fifth intercostal space, MAL 4. Over the lower lobes, posterior side

ANS: 1 Normally, fremitus is most prominent between the scapulae and around the sternum. These are sites where the major bronchi are closest to the chest wall. Fremitus normally decreases as one progress down the chest because more tissue impedes sound transmission.

The nurse is auscultating the lungs of a patient who had been sleeping and notes short, popping, crackling sounds that stop after a few breaths. The nurse recognizes that these breath sounds are: 1. atalectatic crackles, and not pathologic. 2. fine crackles and they may be a sign of pneumonia. 3. vesicular breath sounds. 4. fine wheezes.

ANS: 1 One type of adventitious sound, atelectatic crackles, is not pathologic. They are short, popping, crackling sounds that sound like fine crackles but do not last beyond a few breaths. When sections of alveoli are not fully aerated (as in people who are asleep or in the elderly), they deflate slightly and accumulate secretions. Crackles are heard when these sections are expanded by a few deep breaths. Atelectatic crackles are heard only in the periphery, usually in dependent portions of the lungs, and disappear after the first few breaths or after a cough.

The primary muscles of respiration include the: 1. diaphragm and intercostals. 2. sternomastoids and scaleni. 3. trapezius and rectus abdominis. 4. external obliques and pectoralis major.

ANS: 1 The major muscle of respiration is the diaphragm. The intercostal muscles lift the sternum and elevate the ribs during inspiration, increasing the anteroposterior diameter.

A patient comes to the clinic complaining of a cough that is worse at night but not as bad during the day. The nurse recognizes that this may indicate 1. pneumonia. 2. postnasal drip or sinusitis. 3. exposure to irritants at work. 4. chronic bronchial irritation from smoking.

ANS: 2 A cough that occurs mainly at night may indicate postnasal drip or sinusitis

During palpation of the anterior chest wall, the nurse notes a coarse, crackling sensation over the skin surface. On the basis of these findings, the nurse suspects: 1. tactile fremitus. 2. crepitus. 3. friction rub. 4. adventitious sounds.

ANS: 2 Crepitus is a coarse, crackling sensation palpable over the skin surface. It occurs in subcutaneous emphysema when air escapes from the lung and enters the subcutaneous tissue, as after open thoracic injury or surgery.

Which statement about the apices of the lungs is true? The apices of the lungs: 1. are at the level of the second rib anteriorly. 2. extend 3 to 4 cm above the inner third of the clavicles. 3. are located at the sixth rib anteriorly and the eighth rib laterally. 4. rest on the diaphragm at the fifth intercostal space in the midclavicular line.

ANS: 2 The apex of the lung on the anterior chest is 3 to 4 cm above the inner third of the clavicles. On the posterior chest, the apices are at the level of C7.

The nurse knows that a normal finding when assessing the respiratory system of an elderly adult is: 1. increased thoracic expansion. 2. decreased mobility of the thorax. 3. a decreased anteroposterior diameter. 4. bronchovesicular breath sounds throughout the lungs

ANS: 2 The costal cartilages become calcified with aging, resulting in a less mobile thorax.

A mother brings her 3-month-old infant to the clinic for evaluation of a cold. She tells the nurse that he had had "a runny nose for a week." When performing the physical assessment, the nurse notes that the child has nasal flaring and sternal and intercostal retractions. The nurse's next action should be to: 1. assure the mother that these are normal symptoms of a cold. 2. recognize that these are serious signs and contact the physician. 3. recognize that these are symptoms of rachitic rosary and refer the infant within the week. 4. perform a complete cardiac assessment because these are probably signs of early heart failure.

ANS: 2 The infant is an obligatory nose breather until the age of 3 months. Normally there is no flaring of the nostrils and no sternal or intercostal retraction. Marked retractions of the sternum and intercostal muscles and nasal flaring indicate increased inspiratory effort, as in pneumonia, acute airway obstruction, asthma, and atelectasis.

When considering the biocultural differences in the respiratory systems, the nurse knows that which statement is true? 1. The smallest chest volumes are found in Asians. 2. The largest chest volumes are found in whites. 3. Asians are most likely to contract tuberculosis. 4. Racial differences are of no significance when assessing the respiratory system.

ANS: 2 The largest chest volumes are, in descending order, found whites, then blacks, Asians, and American Indians. Even when the shorter height of Asians is consid- ered, their chest volume remains significantly lower than that of whites and blacks. A disproportionately large number of tuberculosis cases are reported among blacks, most of whom were born in the United States.

During an examination of the anterior thorax, the nurse recalls that the trachea bifurcates anteriorly at the: 1. costal angle. 2. sternal angle. 3. xiphoid process. 4. suprasternal notch.

ANS: 2 The sternal angle marks the site of tracheal bifurcation into the right and left main bronchi; it corresponds with the upper border of the atria of the heart, and it lies above the fourth thoracic vertebra on the back.

The nurse has noted unequal chest expansion and recognizes that this occurs when: 1. the patient is obese. 2. part of the lung is obstructed or collapsed. 3. bulging of the intercostal spaces is present. 4. accessory muscles are used to augment respiratory effort.

ANS: 2 Unequal chest expansion occurs when part of the lung is obstructed or collapsed, as with pneumonia or guarding to avoid postoperative incisional pain or atelectasis.

A teenage patient comes to the emergency department with complaints of an inability to "breathe and a sharp pain in my left chest." The assessment findings include the following: cyanosis, tachypnea, tracheal deviation to the right, decreased tactile fremitus on the left, hyperresonance on the left, and decreased breath sounds on the left. This description is consistent with: 1. bronchitis. 2. a pneumothorax. 3. acute pneumonia. 4. an asthmatic attack.

ANS: 2 With a pneumothorax, free air in the pleural space causes partial or complete lung collapse. If the pneumothorax is large, tachypnea and cyanosis are seen. Unequal chest expansion, decreased or absent tactile fremitus, tracheal deviation to the unaffected side, decreased chest expansion, hyperresonant percussion tones, and decreased or absent breath sounds are assessed.

When assessing the respiratory system of a 4-year-old child, which of the following findings would the nurse expect? 1. Crepitus palpated at the costochondral junctions 2. No diaphragmatic excursion as a result of a child's decreased inspiratory volume 3. The presence of bronchovesicular breath sounds in the peripheral lung fields 4. An irregular respiratory pattern and a respiratory rate of 40 breaths per minute at rest

ANS: 3 Bronchovesicular breath sounds in the peripheral lung fields of the infant and young child up to age 5 or 6 years are a normal finding. Their thin chest walls with underdeveloped musculature do not dampen the sound, as do the thicker chest walls of adults, so breath sounds are louder and harsher.

The nurse knows that bronchovesicular breath sounds are: 1. musical in quality. 2. usually pathological. 3. expected near the major airways. 4. similar to bronchial sounds except that they are shorter in duration.

ANS: 3 Bronchovesicular sounds are heard over major bronchi where fewer alveoli are located: posteriorly, between the scapulae, especially on the right; anteriorly, around the upper sternum in the first and second intercostal spaces.

A woman in her 26th week of pregnancy states that she is "not really short of breath" but feels that she is aware of her breathing and the need to breathe. What is the nurse's best reply? 1. "The diaphragm becomes fixed during pregnancy, making it difficult to take in a deep breath." 2. "The increase in estrogen levels during pregnancy often causes a decrease in the diameter of the rib cage and makes it difficult to breathe." 3. "What you are experiencing is normal. Some women may interpret this as short- ness of breath, but it is a normal finding and nothing is wrong." 4. "This is normal as the fetus grows because of the increased oxygen demand on the mother's body and results in an increased respiratory rate."

ANS: 3 During pregnancy, the woman may develop an increased awareness of the need to breathe. Some women may interpret this as dyspnea, even though structurally nothing is wrong. Estrogen increases relax the chest cage ligaments, causing an increase in transverse diameter. The growing fetus does increase the oxygen demand on the mother's body, but this is met easily by the increasing tidal volume (deeper breathing). Little change occurs in the respiratory rate.

A patient has been admitted to the emergency department with a possible medical diagnosis of pulmonary embolism. The nurse recognizes which assessment findings related to this condition? 1. Absent or decreased breath sounds 2. Productive cough with thin, frothy sputum 3. Chest pain that is worse on deep inspiration, dyspnea 4. Diffuse infiltrates with areas of dullness upon percussion

ANS: 3 Findings for pulmonary embolism include chest pain that is worse on deep inspiration, dyspnea, apprehension, anxiety, restlessness, PaO2 less than 80, diaphoresis, hypotension, crackles, and wheezes.

The nurse knows that auscultation of fine crackles would most likely be noted in which situation? 1. In a healthy 5-year-old child 2. In the pregnant patient 3. In the immediate newborn period 4. In association with a pneumothorax

ANS: 3 Fine crackles are commonly heard in the immediate newborn period as a result of the opening of the airways and clearing of fluid.

The nurse is aware that tactile fremitus is produced by: 1. moisture in the alveoli. 2. air in the subcutaneous tissues. 3. sounds generated from the larynx. 4. blood flow through the pulmonary arteries.

ANS: 3 Fremitus is a palpable vibration. Sounds generated from the larynx are transmitted through patent bronchi and the lung parenchyma to the chest wall where they are felt as vibrations.

During an assessment, the nurse knows that expected assessment findings in the normal adult lung include the presence of: 1. adventitious sounds and limited chest expansion. 2. increased tactile fremitus and dull percussion tones. 3. muffled voice sounds and symmetrical tactile fremitus. 4. absent voice sounds and hyperresonant percussion tones.

ANS: 3 Normal lung findings include symmetric chest expansion, resonant percussion tones, vesicular breath sounds over the peripheral lung fields, no adventitious sounds, and muffled voice sounds.

A 35-year-old recent immigrant is being seen in the clinic for complaints of a cough that is associated with rust-colored sputum, low-grade afternoon fevers, and night sweats for the past 2 months. The nurse's preliminary analysis, based on this history, is that this patient may be suffering from: 1. bronchitis. 2. pneumonia. 3. tuberculosis. 4. pulmonary edema.

ANS: 3 Sputum is not diagnostic alone, but some conditions have characteristic sputum production. Tuberculosis often produces rust-colored sputum in addition to other symptoms of night sweats and low-grade afternoon fevers. Asian immigrants have a high incidence of tuberculosis. Their tuberculosis usually peaks in the first 2 months of entry into the United States.

When auscultating the chest in an adult, the nurse would: 1. instruct the patient to take deep, rapid breaths. 2. instruct the patient to breathe in and out through his or her nose. 3. use the diaphragm of the stethoscope held firmly against the chest. 4. use the bell of the stethoscope held lightly against the chest to avoid friction.

ANS: 3 The diaphragm of the stethoscope held firmly on the chest is the correct way to auscultate breath sounds. The patient should be instructed to breathe through his or her mouth, a little deeper than usual, but not to hyperventilate.

A 65-year-old patient with a history of heart failure comes to the clinic with complaints of "being awakened from sleep with shortness of breath." Which action by the nurse is most appropriate? 1. Obtain a detailed history of the patient's allergies and history of asthma. 2. Tell the patient to sleep on his or her right side to facilitate ease of respirations. 3. Assess for other signs and symptoms of paroxysmal nocturnal dyspnea. 4. Assure the patient that this is normal and will probably resolve within the next week.

ANS: 3 The patient is experiencing paroxysmal nocturnal dyspnea: being awakened from sleep with shortness of breath and the need to be upright to achieve comfort.

The nurse notes hyperresonant percussion tones when percussing the thorax of an infant. The nurse's best action would be to: 1. notify the physician. 2. suspect a pneumothorax. 3. consider this a normal finding. 4. monitor the infant's respiratory rate and rhythm.

ANS: 3 The percussion note of hyperresonance occurs normally in the infant and young child, owing to the relatively thin chest wall. Anything less than hyperresonance would have the same clinical significance as would dullness in the adult.

When performing a respiratory assessment on a patient, the nurse notes a costal angle of approximately 90 degrees. This characteristic is: 1. seen in patients with kyphosis. 2. indicative of pectus excavatum. 3. a normal finding in a healthy adult. 4. an expected finding in a patient with a barrel chest.

ANS: 3 The right and left costal margins form an angle where they meet at the xiphoid process. Usually, this angle is 90 degrees or less. The angle increases when the rib cage is chronically overinflated, as in emphysema.

When auscultating the lungs of an adult patient, the nurse notes that over the posterior lower lobes low-pitched, soft breath sounds are heard, with inspiration being longer than expiration. The nurse knows that these are: 1. sounds normally auscultated over the trachea. 2. bronchial breath sounds and are normal in that location. 3. vesicular breath sounds and are normal in that location. 4. bronchovesicular breath sounds and are normal in that location.

ANS: 3 Vesicular breath sounds are low-pitched, soft sounds with inspiration being longer than expiration. These breath sounds are expected over peripheral lung fields where air flows through smaller bronchioles and alveoli.

A patient has a long history of chronic obstructive pulmonary disease. During the assessment, the nurse is most likely to observe: 1. unequal chest expansion. 2. increased tactile fremitus. 3. atrophied neck and trapezius muscles. 4. an anteroposterior-to-transverse diameter ratio of 1:1.

ANS: 4 An anteroposterior-to-transverse diameter of 1:1 or "barrel chest" is seen in individuals with chronic obstructive pulmonary disease because of hyperinflation of the lungs. The ribs are more horizontal, and the chest appears as if held in continu- ous inspiration. Neck muscles are hypertrophied from aiding in forced respiration. Chest expansion is decreased but symmetric. Decreased tactile fremitus occurs from decreased transmission of vibrations.

During a morning assessment, the nurse notes that the patient's sputum is frothy and pink. Which condition could this finding indicate? 1. Croup 2. Tuberculosis 3. Viral infection 4. Pulmonary edema

ANS: 4 Sputum alone is not diagnostic, but some conditions have characteristic sputum production. Pink, frothy sputum indicates pulmonary edema.

When inspecting the anterior chest of an adult, the nurse should assess for: 1. diaphragmatic excursion. 2. symmetric chest expansion. 3. the presence of breath sounds. 4. the shape and configuration of the chest wall.

ANS: 4 The anterior chest is inspected for the shape and configuration of the chest wall, level of consciousness, skin color and condition, quality of respirations, retraction and bulging of the intercostal spaces, and use of accessory muscles. The other techniques listed are percussion, palpation, and auscultation techniques.

The nurse knows that bronchophony heard upon auscultation is associated with: 1. pneumothorax. 2. hyperresonance. 3. pulmonary consolidation. 4. decreased breath sounds.

ANS: 3 Pathological conditions that increase lung density will enhance transmission of voice sounds.

During percussion, the nurse knows that a dull percussion note elicited over a lung lobe most likely results from: 1. shallow breathing. 2. normal lung tissue. 3. decreased adipose tissue. 4. increased density of lung tissue.

ANS: 4 A dull percussion note indicates an abnormal density in the lungs, as with pneumonia, pleural effusion, atelectasis, or tumor. Resonance is the expected finding in normal lung tissue.

Which of the following describes normal changes in the respiratory system of the older adult? 1. Severe dyspnea is experienced on exertion resulting from changes in the lungs. 2. Respiratory muscle strength increases to compensate for a decreased vital capacity. 3. There is a decrease in small airway closure, leading to problems with atelectasis. 4. The lungs are less elastic and distensible, decreasing their ability to collapse and recoil.

ANS: 4 In the aging adult the lungs are less elastic and distensible, decreasing their ability to collapse and recoil. There is a decreased vital capacity and a loss of intraalveolar septa, causing less surface area for gas exchange. The lung bases become less ventilated, and the older person is at risk for dyspnea with exertion, but this should not be severe (which would suggest the possibility of pathology).

The nurse knows that percussion over an area of atelectasis in the lungs would reveal: 1. dullness. 2. tympany. 3. resonance. 4. hyperresonance.

ANS: 1 A dull percussion note signals an abnormal density in the lungs, as with pneumonia, pleural effusion, atelectasis, or tumor.

The most important technique when progressing from one auscultatory site on the thorax to another is: 1. side-to-side comparison. 2. top-to-bottom comparison. 3. posterior-to-anterior comparison. 4. interspace-by-interspace comparison.

ANS: 1 Side-to-side comparison is most important when auscultating the chest. Listen to at least one full respiration in each location.

When assessing a patient's lungs, the nurse recalls that the left lung: 1. consists of two lobes. 2. is divided by the horizontal fissure. 3. consists primarily of an upper lobe on the posterior chest. 4. is shorter than the right lung because of the underlying stomach.

ANS: 1 The right lung is shorter than the left lung because of the underlying liver. The left lung is narrower than the right lung because the heart bulges to the left. The right lung has three lobes, and the left lung has two lobes. The posterior chest is almost all lower lobe.

Which of the following is true regarding the vertebra prominens? The vertebra prominens is: 1. the spinous process of C7. 2. usually not palpable in most individuals. 3. opposite the interior border of the scapula. 4. located next to the manubrium of the sternum.

ANS: 1 The spinous process of C7 is the vertebra prominens. It is the most prominent bony spur protruding at the base of the neck. Counting ribs and intercostal spaces on the posterior thorax is difficult because of the muscles and soft tissue. The vertebra prominens is easier to identify and is used as a starting point in counting thoracic processes and identifying landmarks on the posterior chest.

Air passing through narrowed bronchioles would produce which of the following adventitious sounds? 1. Wheezes 2. Bronchial sounds 3. Bronchophony 4. Whispered pectoriloquy

ANS: 1 Wheezes are caused by air squeezed or compressed through passageways narrowed almost to closure by collapsing, swelling, secretions, or tumors.