Chapter 19: Assessing Thorax and Lungs

Which terms are used to identify the lobes of the right lung? Select all that apply.

middle lobe upper lobe lower lobe

The nurse percusses the lungs of a patient with pneumonia. What percussion note would the nurse expect to document?

Dullness

A client comes to the clinic and states, "I have a bad cold and am having trouble breathing." The nurse checks the client's breath sounds and hears bilateral fine crackles at the base. Of what is this finding indicative?

Fluid in the alveoli

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?

Teaching strategies to reduce complications of existing diagnoses

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 patient's lungs?

Vesicular

The nurse demonstrates appropriate technique when using what part of the hand to assess for fremitus in a client?

Palmar base

A nurse performs a respiratory assessment on a client and notes the respiratory rate to be 8 breaths per minute. The nurse knows the proper term for this rate is what?

Bradypnea

Which of the following occurs in respiratory distress?

Skin between the ribs moves inward with inspiration

During the lung assessment for a client with pneumonia, the nurse auscultates low-pitched, bubbling, moist sounds that persist from early inspiration to early expiration. How should the nurse document these sounds?

Coarse crackles

The nurse is reviewing the client's health history and notes he has pectus excavatum. The nurse would assess the client for what?

Funnel chest

Under normal circumstances, the strongest stimulus to breathe is

Hypercapnia

The nurse auscultates the base of the lungs to assess for what reason?

It is where fluid occurs with pulmonary edema

While performing an assessment of a client who sustained a chest injury, which physical examination technique should the nurse use to elicit crepitus?

Palpation

The thin double-layered serous membrane that lines the chest cavity is termed

Parietal pleura

The spinous process termed the vertebra prominens is in which cervical vertebra?

Seventh

The apex of each lung is located at the

area slightly above the clavicle

A hospitalized client experiences respiratory distress. The nurse should include which most appropriate client outcome in the plan of care?

Airway patent, breathing quiet, denies dyspnea

While inspecting the thorax, the nurse views it from posterior and lateral positions to assess which of the following?

Anteroposterior to lateral diameter

What type of respiratory pattern would the nurse consider normal in a client with severe heart failure?

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's respirations are associated with diabetic ketoacidosis.

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

Chronic bronchitis

Upon inspection of a client's chest, a nurse observes an increase in the ratio of anteroposterior to transverse diameter. The nurse recognizes this as a finding in which disease process?

Chronic obstrcutive pulmonary disease

A client experiences increasing difficulty taking in a deep breath. For which health problem should the nurse focus when assessing this client?

Chronic obstructive lung disease

A client reports sharp and stabbing chest pain that worsens with deep breathing and coughing. A cardiac cause to this pain is ruled out. The description of the pain is consistent with what respiratory condition?

Pleurisy

A client presents to the health care clinic and reports a recent onset of a persistent cough. The client denies any shortness of breath, change in activity level, or other findings of an acute upper respiratory tract illness. What question by the nurse is most appropriate to further assess the cause for the cough?

"Are you taking any medications on a regular basis?"

A nurse is receiving report from the night shift about four clients. Which client would the nurse see first?

A 64-year-old man with COPD who is short of breath and has a respiratory rate of 32 breaths/min Explanation: 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 preparing to auscultate the posterior thorax of an adult female client. The nurse should

Ask the client to breathe deeply through her mouth

A 21-year-old college senior presents to the clinic reporting shortness of breath and a nonproductive nocturnal cough. She states she used to feel this way only with extreme exercise, but lately she has felt this way continuously. She denies any other upper respiratory, gastrointestinal, and urinary symptoms and says she has no chest pain. Her past medical history is significant only for seasonal allergies, for which she takes a nasal steroid spray; she takes no other medications. She has had no surgeries. Her mother has allergies and eczema; her father has high blood pressure. She is an only child. She denies smoking and illegal drug use but drinks three to four alcoholic beverages per weekend. She is a junior in finance at a local university and has recently started a job as a bartender in town. On examination she is in no acute distress. Temperature is 98.6, blood pressure is 120/80, pulse is 80, and respirations are 20. Head, eyes, ears, nose, and throat examinations are essentially normal. Inspection of her anterior and posterior chest shows no abnormalities. On auscultation of her chest, there is decreased air movement and a high-pitched whistling on expiration in all lobes. Percussion reveals resonant lungs. Which disorder of the thorax or lung does this presentation best describe?

Asthma 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.

Which of the following statements relating to assessment of the lungs and thorax is most accurate?

Bronchitis is characterized by excess mucus production and chronic cough.

A nurse is interviewing a client who complains of dyspnea of sudden onset. Based on this finding, the nurse should suspect which of the following causes?

Bacterial Infection Gradual onset of dyspnea is usually indicative of lung changes such as emphysema, whereas sudden onset is associated with viral or bacterial infections. Lung cancer and sleep apnea are chronic conditions, which would be more likely to result in a gradual onset of dyspnea.

Adventitious sounds related to atelectasis and pulmonary edema are first evident when auscultating what area of the respiratory system?

Bases

The nurse is preparing to percuss a patient's anterior chest area. Which approach will the nurse use for this assessment?

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

Which lung sound possesses the following characteristics? Expiration is longer than inspiration; the sound is louder and higher in pitch with a short silence between inspiration and expiration.

Bronchial

The nurse assesses an adult client's breath sounds and hears sonorous wheezes, primarily during the client's expiration. The nurse should refer the client to a physician for possible

Bronchitis

When auscultating a client's lungs, the nurse hears a sound like Velcro being pulled apart over the client's right middle lobe. How should the nurse document this finding?

Coarse crackles

The thoracic cavity contains which of the following organs? Select all that apply.

Lungs Heart Most of the esophagus

A nurse is palpating the sternum of a client. If the client is healthy, which of the following would characterize his costal angle?

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

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?

Decreasing intensity is normal at the base

The nurse has assessed the respiratory pattern of an adult client. The nurse determines that the client is exhibiting Kussmaul respirations with hyperventilation. The nurse should contact the client's physician because this type of respiratory pattern usually indicates

Diabetic ketoacidosis

Which observation confirms to the nurse that the client is experiencing a normal inspiration?

The thoracic cavity enlarges

A client in the ED tells the nurse that she is having difficulty breathing at rest. What term would the nurse use in documenting this finding?

Dyspnea

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?

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.

A grandmother brings her 13-year-old grandson for evaluation. She noticed last week when he took off his shirt that his breastbone seemed collapsed. He seems embarrassed and says that it has been that way for awhile. He states he has no symptoms from it and that he just tries not to take off his shirt in front of anyone. He denies any shortness of breath, chest pain, or lightheadedness on exertion. His past medical history is unremarkable. He is in sixth grade and just moved in with his grandmother after his father was transferred for a work contract. His mother died several years ago in a car accident. He states that he does not smoke and has never touched alcohol. Examination shows a teenage boy appearing his stated age. Visual examination of his chest reveals that the lower portion of the sternum is depressed. Auscultation of the lungs and heart is unremarkable. What disorder of the thorax best describes these findings?

Funnel chest (pectus excavatum) 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 60-year-old male client presents to the health clinic with a 3-week history of cough, pleuritic chest pain, increasing fatigue, and intermittent fevers. Which data collected in the history should the nurse recognize as risk factors for the development of lung cancer? Select all that apply.

History of radiation exposure Exposure to absestors at work

A client has a history of emphysema. The nurse percussing the client's chest expects to hear what characteristic sound?

Hyperresonance

After percussing a client's lung fields the nurse suspects a client has a chronic lung disease. What sound did the nurse hear to make this clinical determination?

Hyperresonance

A client presents to the health care facility with a 2-week history of persistent dry, hacky cough, chest tightness, and shortness of breath with activity. The client admits to a 1-pack-per-day history of cigarette smoking for 20 years. The nurse observes a respiratory rate of 16 breaths per minute, easy and regular. Which nursing diagnosis should the nurse confirm based on this assessment data?

Impaired Gas Exchange

A nurse is auscultating the bronchi of a client. The nurse understands that the bronchi are located in which of the following locations in the body?

In the mediastinum

A client presents to the health care facility with sudden onset of shortness of breath, inability to lie flat, and a deep, wet cough. A nurse observes a respiratory rate of 18 breaths per minute, use of accessory muscles to breathe, and inability to cough up secretions. Which nursing diagnosis can be confirmed with this data?

Ineffective Airway Clearance

A nurse auscultates a client's lungs and hears fine crackles. What is an appropriate action by the nurse?

Instruct the client to cough forcefully

Which action by a nurse demonstrates the proper sequence for auscultation of the lung fields?

Listen at each site for at least one complete respiratory cycle Explanation: The client is instructed to breathe deeply though the mouth for each area as the nurse listens through inspiration and expiration. The sequence should be performed in an anterior then posterior sequence to avoid missing any areas. The bell is not used for breath sounds because it detects low pitched sound such as abnormal heart sounds.

The clavicles extend from the acromion of the scapula to the part of the sternum termed the

Manubrium

Auscultation of a 23-year-old client's lungs reveals an audible wheeze. What pathological phenomenon underlies wheezing?

Narrowing or partial obstruction of an airway passage

An elderly client reports a feeling of dyspnea with normal activities of daily living. What is an appropriate action by the nurse?

Obser the client's respiratory rate and pattern

A nurse observes a client sitting in the tripod position. What is an appropriate action by the nurse in response to this observation?

Observe for the use of accessory muscles 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.

When auscultating the lungs, the nurse listens over symmetrical lung fields for which of the following?

One deep inspiration and expiration through the open mouth

A client who just underwent hip replacement surgery reports pain at a 10 on a scale of 0 to 10 and receives 4 mg of morphine. A nurse on the orthopedic unit enters the client's room and finds that the client has a respiratory rate of 7 breaths/min. The client is groggy and hard to arouse. What could be contributing to the client's findings?

Opiates, which may cause hypoventilation Explanation: Opiates may reduce the ability of the brain to trigger breathing, causing hypoventilation (slow breathing). This scenario does not describe a reaction to anesthesia, and it is not a normal finding following surgery.

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?

Patient C

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 excavatum

The nurse obtains a flat sound when percussing the right lower lobe of a patient. What does this assessment finding indicate to the nurse?

Pleural effusion= excess fluid builds up AROUND the lungs not in the lungs

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?

Pneumonia

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

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

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

When percussing the anterior chest for tone, a nurse should anticipate what tone over the majority of the lung fields?

Resonance

A client is brought to the emergency department by ambulance after being involved in a motor vehicle accident. The nurse finds that he has decreased breath sounds over the left lung fields. What might the nurse suspect is the cause?

Pneumothorax

The client tells the nurse that he has been coughing up pink, frothy sputum. The nurse notifies the health care provider because the client may have what condition?

Pulmonary edema

A client arrives in the emergency department after a severe motor vehicle accident. The nurse observes irregular respirations of varying depth and rate followed by periods of apnea. What pathophysiological process is likely the cause of this breathing pattern?

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

A nurse is assessing a client with acute asthma. Which adventitious breath sound should the nurse expect to hear in this client?

Sibilant wheezes heard primarily during expiration but may also be heard on inspiration 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.

A high-pitched crowing sound from the upper airway results from tracheal or laryngeal spasm and is called what?

Stridor Stridor, a high-pitched crowing sound from the upper airway, results from tracheal or laryngeal spasm. In severe laryngospasm, the larynx may completely close off. This life-threatening emergency requires immediate medical assistance. Crackles, wheezes, and rales are adventitious breath sounds heard upon auscultation of the lungs.

In palpating the chest of a client, a nurse feels a U-shaped indentation on the superior border of the manubrium. The nurse recognizes this landmark as which of the following?

Suprasternal notch The sternum, or breastbone, lies in the center of the chest anteriorly and is divided into three parts: the manubrium, the body, and the xiphoid process. The manubrium connects laterally with the clavicles (collar bones) and the first two pairs of ribs. The clavicles extend from the manubrium to the acromion of the scapula. A U-shaped indentation located on the superior border of the manubrium is an important landmark known as the suprasternal notch. A few centimeters below the suprasternal notch, a bony ridge can be palpated at the point where the manubrium articulates with the body of the sternum. This landmark, often referred to as the sternal angle (or angle of Louis), is also the location of the second pair of ribs and becomes a reference point for counting ribs and intercostal spaces.

A new nurse on the telemetry unit is reviewing information about how to correctly read electrocardiograms. The nurse is expected to know that the PR interval represents what event?

The time from firing of the sinoatrial (SA) node to the beginning of depolarization in the ventricle

Which characteristic associated with respiratory effort should be considered when planning care for a client diagnosed with a brainstem injury?

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

When assessing a patient with asthma, the nurse would expect to hear wheezing.

True

Which finding during an assessment of a client should alert the nurse to the presence of a persistent atelectasis?

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.

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 foreign body obstruction

The lining of the trachea and bronchi, which serves to remove dust, foreign bodies, and bacteria, is termed the

cilia

What would the nurse expect to hear when auscultating the lungs of a client diagnosed with pleuritis?

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 client reports severe pain when breathing in deeply. The description suggests to the nurse that the client is experiencing which respiratory condition?

inflammation of the parietal pleura