ch 19. Lungs & thorax

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

Observe for the use of accessory muscles

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

Observe the client's respiratory rate and pattern

How should a nurse position a client to accuralty auscualte the right middle lobe of the lung ?

Move the right arm away from the body

What characteristic nail color should the nurse recognize as an indication of hypoxia?

cyanotic

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 nurse auscultates a client's lung and heats fine crackles. What is an appropriate action by the nurse?

instruct the client to cough forcefully

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

less than 90 degrees

Which characteristic of a cough should alert the nurse to assess the client for other findings of sinusitis?

nighttime when lying down

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

suprasternal notch

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 primary during expiration but may also be heard on inspiration

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

Unequal expansion of the chest

A nurse is auscultating the voice sounds of a client with consolidation in his left lower lobe of his lung due to tumor, Which of the following findings should the nurse expect on perfmcoring pectoriloquy?

1-2-3 is heard clearly

A client presents to the health are clinic and reports a recent onset of 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 bye the nurse is most appropriate to the further assess the cause for the cough?

Are you taking any medications on a regular basis?

A nurse cares for a client admitted after falling off a ladder onto a concrete floor. The client is nit arousable and pupils are fixed and dilated. When performing a respiratory assessment, the nurse recognizes which breathing pattern as normal for clients with brain damage?

Biot's

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 type of breathe sounds should a nurse anticipate on auscultation of the right lower lobe in a client with right lower lobe pneumonia

Bronchial

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

Chronic obstructive pulmonary disease

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?

Client needs to speak louder

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

Coarse crackles

During the assessment of a client with a pneumothorax, what change should the nurse anticipate when osculating for fremitus?

Decreased

A nurse inspects the anterior thorax of a client with emphysema. Which change in the thorax should the nurse recognize as normal for this client?

Horizontal position to the ribs with a costal angle of greater than 90 degrees

A client is concerned about developing lung cancer, as he smoked for years. He tells the nurse that he quit smoking last year but wonders if there is anything else he can do to reduce his risk for developing this disease. Which of the following should the nurse recommend ?

Having his home checked for radon

A client reports to the nurse that he experiences fatigue during the day, has difficulty sleeping sing down and often wakes up at night feeling short of breath. The nurse should assess this client for other findings related to what disease process?

Heart failure

A nurse assesses the respiration pattern on a client who arrives in the emergency department due to an overdose of narcotics. The nurse notes that the respirations are decreased in rate and depth, and have an irregular pattern. How should the nurse document this finding ?

Hypoventilation

A client presents to the health care facility with a 2-week history of persistent dry, hack 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 the assessment data?

Impaired has exchange

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 breathes 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

When performing a physical examination for a client with scoliosis, which physical characteristic should the nurse expect to find during the assessment?

Lateral deviation of the spinous processes

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

Listen at each site for at least one compete respiratory cycle

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

Palpation

Which action by a nurse demonstrates proper technique for assessment of chest expansion?

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

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

Resonance

A client is admitted to the health care facility with a diagnosis of left lower lobe pneumonia. What change in ego phony should the nurse expect to find in the left lower lobe?

Sound is louder and sounds like "A"

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

Which characteristic feature of the sternum should the nurse observe in a client with the diagnosis of pectus carinatum?

forward protrusion

A nurse is auscultating a client's chest for breath sounds. The nurse recognizes that which of the following is the strongest stimulus to breathe?

hypercapnia