Chapter 19: Thorax and Lungs
The thin double-layered serous membrane that lines the chest cavity is termed a) visceral pleura. b) pulmonary pleura. c) parietal pleura. d) thoracic pleura.
parietal pleura. Explanation: The parietal pleura line the chest cavity
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) bronchitis. c) pleuritis. d) asthma.
pneumonia. Explanation: 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) repeat the letter "A." d) whisper the phrase "one-two-three."
repeat the phrase "ninety-nine." Explanation: To assess bronchophony ask the client to repeat the phrase "ninety-nine" while you auscultate the chest wall.
The thoracic cavity contains which of the following organs? Select all that apply. a) Lungs b) Stomach c) Pancreas d) Heart e) Most of the esophagus
• Heart • Lungs • Most of the esophagus Explanation: 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.
Which of the following muscles is primarily responsible for thoracic cavity enlargement? a) Parasternal b) Sternomastoid c) Scalene d) Diaphragm
Diaphragm Explanation: The diaphragm is the primary muscle of inspiration; when it contracts, its descent enlarges the thoracic cavity.
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) Shortness of breath b) Tachypnea c) Dyspnea d) Anxiety
Dyspnea Explanation: 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. (less)
Which of the following occurs in respiratory distress? a) Skin between the ribs moves inward with inspiration. b) The client speaks in sentences of 10-20 words. c) Client torso leans posteriorly. d) Neck muscles are relaxed.
Skin between the ribs moves inward with inspiration. Explanation: This description is consistent with retractions, which occur with respiratory distress. Other features include speaking in short sentences, use of accessory muscles, leaning forward to gain mechanical advantage for the diaphragm, and pursed lip breathing in which the client exhales against the lips, which are pressed together.
Which ribs are considered "floating ribs"? a) 9th and 10th b) 11th and 12th c) 10th and 11th d) 8th and 9th
11th and 12th Explanation: Note that the costal cartilages of the first seven ribs articulate with the sternum; the cartilages of the 8th, 9th, and 10th ribs articulate with the costal cartilages just above them. The 11th and 12th ribs, the "floating ribs," have no anterior attachments. The cartilaginous tip of the 11th rib usually can be felt laterally, and the 12th rib may be felt posteriorly. On palpation, costal cartilages and ribs feel identical
A nurse is palpating the sternum of a client. If the client is healthy, which of the following would characterize his costal angle? a) 100-110 degrees b) <90 degrees c) 90-100 degrees d) >110 degrees
<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
Good to know about stridor and pluerisy What would the nurse expect to hear when auscultating the lungs of a client with pleuritis?
ANS: Friction rub A patient with pleuritis will exhibit a pleural friction rub upon auscultation. This is the sound made when pleurae become inflamed and rub together during respiration. The sound is superficial, coarse, and low-pitched, as if two pieces of leather are being rubbed together. Stridor is associated with croup, acute epiglottitis in children, and foreign body inhalation. Crackles are associated with several diseases, such as pneumonia, heart failure, chronic bronchitis, and others (see Table 18-6). Wheezes are associated with diffuse airway obstruction caused by acute asthma or chronic emphysema.
Dyspnea, an uncomfortable awareness of breathing that is inappropriate to the level of exertion, is what? a) Air hunger b) Prolonged inspiration c) Painful breathing d) Audible breathing
Air hunger Explanation: Dyspnea is air hunger, a nonpainful but uncomfortable awareness of breathing that is inappropriate to the level of exertion, commonly termed shortness of breath
While inspecting the thorax, the nurse views it from posterior and lateral positions to assess which of the following? a) Curvature of the cervical spine b) Inflammation of the costochondral junction c) Anteroposterior to lateral diameter d) Position of the trachea
Anteroposterior to lateral diameter Explanation: An important component of chest inspection is assessment of the anteroposterior diameter versus the transverse diameter. This is achieved by viewing the client from the back and side. Costochondral inflammation and tracheal position are not assessed in this way, and assessment of the cervical spine is not a central goal of thoracic inspection
Adventitious sounds related to atelectasis and pulmonary edema are first evident when auscultating what area of the respiratory system? a) Bronchi b) Bases c) Trachea d) Apices
Bases Explanation: Careful auscultation of the bases is important because they are often the first area to collapse with atelectasis when a patient is immobile. This is also where fluid collects in a pleural effusion (outside the lungs) or with pulmonary edema (in the lungs) in heart failure
The nurse is preparing to percuss a patient's anterior chest area. Which approach will the nurse use for this assessment? a) Begin at the sternal notch and percuss all areas on the right chest then all areas on the left chest. b) Begin at the sternal notch and percuss all areas on the left chest then all areas on the right chest. c) Begin above the right clavicle and percuss each section comparing the right chest with the left chest. d) Begin above the left clavicle and percuss all areas on the left chest, then reverse the process and assess the right chest moving upward from the liver.
Begin above the right clavicle and percuss each section comparing the right chest with the left chest. Explanation: When percussing a patient's anterior chest, the nurse should begin above the level of the clavicles to assess the lung apex. The nurse should assess the right lung area and then the left. The nurse should proceed in a methodical manner and assess each lung area, comparing right to left. The nurse should not percuss all areas on the right side of the chest before assessing the left chest. The nurse should not percuss all areas on the left side of the chest before assessing the right chest. The nurse should not complete the assessment of the left chest and then reverse the process, assessing upward from the liver.
A nurse cares for a client admitted after falling off a ladder onto a concrete floor. The client is not 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? a) Kussmaul's b) Retractive c) Cheyne-Stokes d) Biot's
Biot's Explanation: In people with irritation or brain damage, the respiratory pattern will be irregular and characterized by varying depth and rate followed by periods of apnea, which is known as Biot's respiration. Cheyne-Stokes is a regular pattern characterized by alternating periods of deep, rapid breathing followed by periods of apnea. Retractive is not an observable pattern of respirations. Kussmaul's is seen in clients with diabetic ketoacidosis and are characterized by deep but rapid respirations similar to hyperventilation.
A nurse performs a respiratory assessment on a client and notes the respiratory rate to be 10 breaths per minute. The nurse knows the proper term for this rate is what? a) Hyperventilation b) Tachypnea c) Bradypnea d) Hypoventilation
Bradypnea Explanation: A respiratory rate less than 10 breaths per minute is called bradypnea. Tachypnea is a respiratory rate greater than 24 breaths per minute. Hyperventilation is used to describe respirations that are increased in rate and depth. Hypoventilation is a rate that is decreased with a decrease in depth, and with an irregular pattern
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) Loud and very loud percussion notes denote pathological findings. c) Bronchitis is characterized by excess mucus production and chronic cough. d) Moderate to severe chest pain is associated with a cardiac etiology, while mild to moderate chest pain is most often respiratory in origin.
Bronchitis is characterized by excess mucus production and chronic cough. Explanation: 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
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? a) Chronic obstructive pulmonary disease b) Pneumothorax c) Tuberculosis d) Carcinoma of the lungs
Chronic obstructive pulmonary disease An increase in the anterior posterior diameter is seen in clients with chronic obstructive pulmonary disease. This occurs be because of air trapping in the airways that causes hyperinflation and over distention. Carcinoma of the lungs, pneumothorax, and tuberculosis do not change the chest diameter
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) Chronic obstructive pulmonary disease (COPD) b) Spontaneous pneumothorax c) Asthma d) Pneumonia
Chronic obstructive pulmonary disease (COPD) Explanation: 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.
During the lung assessment for a client with pneumonia, the nurse auscultates low-pitched, bubbling, moist sounds that persist from early inspiration to early expiration. How should the nurse document these sounds? a) Sonorous wheezes b) Sibilant wheezes c) Coarse crackles d) Pleural friction rubs
Coarse crackles Explanation: Low-pitched bubbling, moist sounds that persists from early inspiration to early expiration and sounds like softly separating Velcro should be documented as coarse crackles. These sounds are produced when inhaled air comes into contact with secretions in the large bronchi and trachea. Pleural friction rub is low-pitched, dry, grating sound that is superficial and occurs during both inspiration and expiration. Sonorous wheezes are low-pitched snoring or moaning sounds that may be heard primarily during expiration but may be heard throughout the respiratory cycle. Sibilant wheezes are high-pitched musical sounds heard primarily during expiration but may also be heard on inspiration.
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) No fluid present b) Fluid in the bronchioles c) Fluid in the bronchus d) Fluid in the alveoli
Fluid in the alveoli Explanation: 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 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? a) Bradypnea b) Cheyne-Stokes respiration c) Biot's respiration d) Hypoventilation
Hypoventilation Explanation: Hypoventilation is decreased rate, decreased depth, and irregular pattern of respiration. A client with regular pattern characterized by alternating periods of deep, rapid breathing followed by periods of apnea has Cheyne-Stokes respiration. A client with irregular pattern characterized by varying depth and rate of respirations followed by periods of apnea has Biot's respiration. A client with bradypnea may have a regular respiration rate of less than 10/min
A client presents to the health care facility with a two (2) week history of persistent dry, hacky cough, chest tightness, and shortness of breath with activity. The client admits to a one (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) Impaired Gas Exchange b) Ineffective Airway Clearance c) Risk for Imbalanced Nutrition d) Disturbed Sleep Pattern
Impaired Gas Exchange Explanation: Impaired Gas Exchange related to chronic lung tissue damage secondary to chronic smoking can be confirmed because 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 is 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) Rest the arms on the knees b) Move the right arm away from the body c) Lean forward at the waist d) Lateral with the right lung facing up
Move the right arm away from the body Explanation: 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 love 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
A nurse observes a client sitting in the tripod position. What is an appropriate action by the nurse in response to this observation? a) Auscultate for the presence of crackles b) Percuss to determine diaphragmatic excursion c) Observe for the use of accessory muscles d) Palpate for tactile fremitus
Observe for the use of accessory muscles Explanation: 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.
An elderly client reports a feeling of dyspnea with normal activities of daily living. What is an appropriate action by the nurse? a) Ask the client how long they have to rest between activities b) Assess for symmetry of chest expansion c) Report this to the health care provider immediately d) Observe the client's respiratory rate and pattern
Observe the client's respiratory rate and pattern Explanation: It is normal for elderly clients to feel short of breath or dyspneic with activities of daily living due to age related changes of loss of elasticity, fewer functional capillaries, and loss of lung resiliency. Observing chest expansion would be appropriate assessment for a client with a pneumothorax. This finding does not need to be reported to the health care provider unless accompanied by other findings of inadequate oxygenation. Asking the client how long they need to rest between activities will not provide the nurse any objective information to differentiate the problem
When auscultating the lungs, the nurse listens over symmetrical lung fields for which of the following? a) Two full breaths every 10 seconds through the nose b) One deep inspiration and expiration through the open mouth c) One quiet full inspiration through pursed lips d) Two full breaths in through the mouth and out through the nose
One deep inspiration and expiration through the open mouth Explanation: Lung auscultation is performed for one full breath over symmetrical lung fields. The client should be encouraged to breathe deeply through an 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? a) Nothing, this is normal following surgery b) Opiates, which may cause hyperventilation c) Anesthesia, from surgery that morning d) Opiates, which may cause hypoventilation
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
Which of the following would be best for a nurse to use when assessing for fremitus in a client? a) Pads of fingers b) Dorsal hand surface c) Fist d) Palmar base (ulnar surface)
Palmar base (ulnar surface) Explanation: 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. Fingerpads 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 patients have recently been admitted. Patient A has an arrhythmia diagnosed as atrial fibrillation; Patient B is in chronic congestive heart failure; Patient C is assessed and found to have a probable pulmonary embolism; Patient D complains of chest pain relieved by nitroglycerin and rest. Which patient would be the nurse's highest priority? a) Patient D b) Patient C c) Patient B d) Patient A
Patient C Explanation: 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
A client is diagnosed with heart failure. The nurse would most likely assess the sputum color as which of the following? a) Rust b) White c) Yellow d) Pink
Pink Explanation: 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) Beginning at the scapular line, percuss the intercostal spaces along both sides of the posterior chest b) Place both hands on the posterior chest at T9, press thumbs together, and then ask client to take a deep breath c) Place the stethoscope on the posterior chest wall, ask the client to take a deep breath, and observe chest rise and fall d) Use the ball of both hands to feel for vibrations in a symmetrical pattern across the posterior chest
Place both hands on the posterior chest at T9, press thumbs together, and then ask client to take a deep breath Explanation: 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 T110 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.
The nurse obtains a flat sound when percussing the right lower lobe of a patient. What does this assessment finding indicate to the nurse? a) Healthy lung tissue b) Pleural effusion c) Chronic bronchitis d) Gastric air bubble
Pleural effusion Explanation: 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. Resonance is the percussion sound associated with chronic bronchitis
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? a) Pleurisy b) Asthma c) Pneumonia d) Rales
Pleurisy Explanation: Pleurisy can follow inflammation of the parietal pleura. Patients usually describe such pain as sharp or stabbing, worsening with deep breathing or coughing. Pneumonia does not always cause pain on respiration nor does asthma. Rales are an adventitious breath sound, not a respiratory condition
A 47-year-old receptionist comes to the office with fever, shortness of breath, and a productive cough with golden sputum. She says she had a cold last week and her symptoms have only worsened despite using over-the-counter cold remedies. She denies any weight gain, weight loss, or cardiac or gastrointestinal symptoms. Her past medical history includes type 2 diabetes for 5 years and high cholesterol level. She takes an oral medication for both diseases. She has had no surgeries. She denies tobacco, alcohol, or drug use. Her mother has diabetes and high blood pressure. Her father passed away from colon cancer. Examination reveals a middle-aged woman appearing her stated age. She looks ill and her temperature is elevated at 101 degrees Farenheit. Her blood pressure and pulse are unremarkable. Her head, eyes, ears, nose, and throat examination are unremarkable except for edema of the nasal turbinates. On auscultation she has decreased air movement and coarse crackles are heard over the left lower lobe. There is dullness on percussion, increased fremitus during palpation, and egophony and whispered pectoriloquy on auscultation. What disorder of the thorax or lung best describes her symptoms? a) Spontaneous pneumothorax b) Asthma c) Chronic obstructive pulmonary disease (COPD) d) Pneumonia
Pneumonia Explanation: 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 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) Muscular weakness b) Pneumothorax c) Asthma d) Atelectasis
Pneumothorax Explanation: 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)
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) Atelectasis b) Infection c) Tuberculosis d) Pulmonary edema
Pulmonary edema Explanation: 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
The spinous process termed the vertebra prominens is in which cervical vertebra? a) Seventh. b) Sixth. c) Eighth. d) Fifth.
Seventh. Explanation: 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 client from a severe motor vehicle accident arrives in the emergency department. The nurse observes irregular respirations of varying depth and rate followed by periods of apnea. Which of the following would the nurse suspect? a) Narcotic overdose b) Severe brain damage c) Diabetic ketoacidosis d) Renal failure
Severe brain damage Correct 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 high-pitched crowing sound from the upper airway results from tracheal or laryngeal spasm and is called what? a) Rales b) Wheezes c) Crackles d) Stridor
Stridor Explanation: 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.
A person with a barrel chest has a problem doing what? a) Coughing b) Breathing at a normal respiratory rate c) Expelling excess oxygen d) Taking a deep breath
Taking a deep breath Explanation: Auscultation of all lung fields may not be possible because deep breathing generally worsens the level of fatigue in patients with pulmonary disorders.
A 72-year-old woman has been admitted to the hospital for treatment of bacterial pneumonia. At the beginning of shift, the nurse notes that the client's previously existing wheeze is not as loud as it had been the day prior and is now audible only on inspiration. How should the nurse best interpret this change in the client's condition? a) The apparent decrease in the client's wheezing signals that antibiotic therapy is effective. b) The client is displaying a comorbidity of asthma. c) Inspiratory wheezing suggests that the client's basilar secretions have become consolidated. d) The client's upper airway may be partially obstructed.
The client's upper airway may be partially obstructed. Explanation: Stridor indicates a partial obstruction of the larynx or trachea and necessitates immediate intervention. It is not a sign of improvement in the client's condition, consolidation of secretions, or the presence of asthma.
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) exercise-induced asthma b) increased secretions c) a severe cold d) a foreign body obstruction
a foreign body obstruction Reference: 384
The nurse is preparing to auscultate the posterior thorax of an adult female client. The nurse should a) ask the client to breathe deeply through her mouth. b) place the bell of the stethoscope firmly on the posterior chest wall. c) auscultate from the base of the lungs to the apices. d) ask the client to breathe normally through her nose.
ask the client to breathe deeply through her mouth. Explanation: 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 lining of the trachea and bronchi, which serves to remove dust, foreign bodies, and bacteria, is termed the a) alveolar ducts. b) alveolar sacs. c) bronchioles. d) cilia.
cilia. Explanation: The trachea and bronchi are lined with mucous membranes containing cilia. These hair-like projections help sweep dust, foreign bodies, and bacteria that have been trapped by the mucus toward the mouth for removal
Under normal circumstances, the strongest stimulus to breathe is a) hypercapnia. b) hypoxemia. c) hypocapnia. d) pH changes.
hypercapnia. Explanation: 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) resonance b) flat c) hyperresonance d) dull
hyperresonance Explanation: Generalized hyperresonance may be heard over hyperinflated lungs found in patients 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.
