Chapter 19: Assessing the Thorax and Lungs PrepU

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.

The nurse is planning a presentation to a group of high school students on the topic of lung cancer. Which of the following should the nurse plan to include in the presentation? a. Compared with whites in the United States, African Americans have a lower incidence of lung cancer. b. Lung cancer is the third leading cause of death in the United States. c. There is a higher incidence of lung cancer in women than men in the United States. d. Studies have indicated that there is a genetic component in the development of lung cancer.

d. Studies have indicated that there is a genetic component in the development of lung cancer. The risk for lung cancer is thought to be partially based on genetics. A history of certain respiratory diseases (asthma, emphysema) in a family may increase the risk for development of the disease.

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 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.

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

d. hypercapnia. 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? a. flat b. dull c. resonance d. hyperresonance

d. hyperresonance 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.

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.

The nurse is assessing a client's thorax. Which structures should the nurse identify as articulating anteriorly with the 10th rib? a. nothing b. sternum c. the spine d. previous rib cartilages

d. previous rib cartilages The cartilages of the 8th, 9th, and 10th ribs articulate with the costal cartilages just above them. The costal cartilages of the first seven ribs articulate with the sternum. The 11th and 12th ribs, the "floating ribs," have no anterior attachments.

The nurse is assessing a client's readiness to quit smoking. Place in order the steps in which the nurse will conduct this assessment. Assess willingness to quit Arrange follow-up Ask about tobacco use Advise to quit Assist to quit

1. Ask about tobacco use 2. Advise to quit 3. Assess willingness to quit 4. Assist to quit 5. Arrange follow-up 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 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.

The nurse is auscultating a client's breath sounds. What should the nurse do first after hearing an unusual sound? a. Ask the client to cough b. Change the client's position c. Compare the sound with the other side d. Listen again with the bell of the stethoscope

a. Ask the client to cough If an abnormal sound is heard during auscultation, always have the client cough and then listen again. Coughing may clear the lungs. There is no reason for the client to change position. Lung sounds should be compared but the abnormal sound needs to be addressed first. The diaphragm of the stethoscope is used to auscultate breath sounds.

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.

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 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.

A nurse asks a client to say "ninety-nine" while palpating the posterior thorax. The nurse is demonstrating effective technique in assessing for what respiratory characteristic? a. Fremitus b. Egophony c. Chest expansion d. Bronchophony

a. Fremitus Fremitus is assessed by asking a client to say 'ninety-nine' as the nurse palpates the thorax. Bronchophony is assessed by asking the client to say 'ninety-nine' as the nurse auscultates the chest wall. Chest expansion is assessed by measuring the distance the examiner's thumbs move when the client takes a deep breath. Egophony is assessed by having the client repeat the letter 'e' as the nurse auscultates.

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 broncholaryngospasms, 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? 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.

The thoracic cavity contains which of the following organs? Select all that apply. a. Heart b. Lungs c. Most of the esophagus d. Stomach e. Pancreas

a. Heart b. Lungs c. 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.

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.

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.

While performing an assessment of a client who sustained a chest injury, which physical examination technique should the nurse use to elicit crepitus? a. Palpation b. Auscultation c. Percussion d. Inspection

a. Palpation 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.

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 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).

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.

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 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.

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

Which pleural membrane lines the chest cavity? a. parietal pleura b. pulmonary pleura c. visceral pleura d. thoracic pleura

a. parietal pleura 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 an adult client's lungs during the postoperative period, the nurse detects coarse crackles. The nurse should refer the client to a physician for possible a. pneumonia. b. pleuritis. c. bronchitis. d. asthma.

a. pneumonia. Crackles occurring late in inspiration are associated with restrictive diseases such as pneumonia.

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

A hospitalized client experiences respiratory distress. The nurse should include which most appropriate client outcome in the plan of care? a. Gas exchange with oxygen saturation greater than 85% b. Airway patent, breathing quiet, denies dyspnea c. Client maintains safety; no falls d. Pain level stabilized at client goal

b. Airway patent, breathing quiet, denies dyspnea 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.

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

b. Chronic obstructive pulmonary disease (COPD) 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.

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 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.

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.

Which characteristic feature of the sternum should the nurse observe in a client with the diagnosis of pectus carinatum? a. Sunken along with the adjacent cartilages b. Forward protrusion c. Midline and straight d. Horizontal sternum with increased intercostal angle

b. Forward protrusion 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.

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) 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.

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? a. At the level of the 12th rib on the left scapular line b. In the mediastinum c. At the level of the 8th rib on the right mid-clavicular line d. At the base of the lungs

b. In the mediastinum 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.

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.

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 The trachea bifurcates into its mainstem bronchi at the levels of the sternal angle anteriorly and the T4 spinous process posteriorly.

Which assessment observation should suggest that the client may be experiencing chronic obstructive pulmonary disease (COPD)? a. The trachea is displaced laterally. b. The chest is measured to be deeper than it is wide. c. There is a unilateral decrease in chest expansion. d. There is tenderness over rib area.

b. The chest is measured to be deeper than it is wide. Observe the shape of the chest, which is normally wider than it is deep. The ratio of the anteroposterior (AP) diameter to the lateral chest diameter is usually 0.70-0.75 up to 0.90 and increases in cases of chronic obstructive pulmonary disease (COPD). Lateral displacement of the trachea may be seen in pneumothorax, pleural effusion, or atelectasis. Causes of unilateral decrease or delay in chest expansion include pleural effusion and lobar pneumonia. Tenderness over rib area is associated with a fracture.

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? a. Bronchovesicular b. Vesicular c. Bronchial d. Tracheal

b. Vesicular 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 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.

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 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.

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.

What color of sputum would support the diagnosis of heart failure? a. White b. Yellow c. Pink d. Rust

c. Pink 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? a. Use the ball of both hands to feel for vibrations in a symmetrical pattern across the posterior chest b. Beginning at the scapular line, percuss the intercostal spaces along both sides of the posterior chest c. Place both hands on the posterior chest at T9, press thumbs together, and then ask client to take a deep breath d. Place the stethoscope on the posterior chest wall, ask the client to take a deep breath, and observe chest rise and fall

c. Place both hands on the posterior chest at T9, press thumbs together, and then ask client to take a deep breath 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 T10 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.

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.

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 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 nurse is preparing to auscultate the posterior thorax of an adult female client. The nurse should a. place the bell of the stethoscope firmly on the posterior chest wall. b. auscultate from the base of the lungs to the apices. c. ask the client to breathe deeply through her mouth. d. ask the client to breathe normally through her nose.

c. ask the client to breathe deeply through her mouth. 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.

The client reports severe pain when breathing in deeply. The description suggests to the nurse that the client is experiencing which respiratory condition? a. ineffective innervation of the of the parietal pleura by the phrenic nerve b. an accumulation of fluid between the lungs and the visceral pleura c. inflammation of the parietal pleura d. an increase of sensory stimulation in the visceral pleura

c. inflammation of the parietal pleura 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 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 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.

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 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? a. Anxiety b. Pulmonary embolism c. Congestive heart failure d. Chronic obstructive lung disease

d. Chronic obstructive lung disease 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.

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.

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 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.

How should a nurse position a client to accurately auscultate the right middle lobe of the lung? a. Lateral with the right lung facing up b. Lean forward at the waist c. Rest the arms on the knees d. Move the right arm away from the body

d. Move the right arm away from the body 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 to not allow the right middle lobe to be exposed for auscultation.

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.