HA- Nursing CH 18

A nurse is receiving report from the night shift about four patients. Which patient 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

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

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

Nighttime when lying down

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

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 use of accessory muscles

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

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

Observe the client's respiratory rate and pattern

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

How should a nurse position a client to accurately ausculate the right middle lobe of the lung?

Move the right arm away form the body

How should a nurse position a client to accurately auscultate 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

Identify the location where vesicular, bronchovesicular, bronchial, and tracheal lung sounds are heard

over most of both lungs between the scapulae over the manubrium over the trachea in the neck

The thoracic cavity contains which of the following organs?

• Heart • Lungs • Most of the esophagus

Which of the following occurs in respiratory distress?

Skin between the ribs moves inward with inspiration.

A patient has sustained a brainstem injury. Which of the following would the nurse need to keep in mind about this patient's respiratory effort?

There is loss of involuntary respiratory control

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

A nurse palpates for tactile fremitus & notes that the vibrations diminish toward the base of the lungs. What should the nurse recognize about this finding?

Decreased intensity is normal at the base

A client presents to health care clinic & reports 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 by the nurse is most appropriate to further assess the cause for the cough?

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

A 60-year-old male client presents to the health care clinic w/ 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?

African American Works in a chemical plant

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

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.

A patient has a history of emphysema. The nurse percusses the chest, expecting to find which of the following?

Hyperresonance

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 client's with brain damage?

Biot's

A nurse performs a respiratory assessment on a client & notes the respiratory rate to be 10 breaths per min. The nurse knows the proper term for this rate is what?

Bradypnea

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?

Bradypnea

WHich type of breath sounds should a nurse anticipate on ausculation of the right lower lobe in a client w/ right lobe pneumonia?

Bronchial

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

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

Upon entering the examination room, a nurse observes that the patient is leaning forward with arms supporting body weight. The nurse would most likely suspect which of the following?

Chronic obstructive pulmonary disease

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 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?

Chronic obstructive pulmonary disease (COPD)

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

Coarse crackles

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

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

Correct response: A 64-year-old man with COPD who is short of breath and has a respiratory rate of 32 breaths/min

During the assessment of a client w/ pneumothorax, what changes should the nurse anticipate when auculating for fremitus?

Decreased

Which of the following muscles is primarily responsible for thoracic cavity enlargement?

Diaphragm

A patient 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

Which abnormal respiratory finding should the nurse expect to observe upon assessment of a client w/ a pleural effusion?

Dyspnea on exertion & dry, nonproductive cough

A patient with lobar pneumonia would have muffled and indistinct spoken voice sounds.

False

A 26-year-old woman comes to the clinic and states, "I have a bad cold and am having trouble breathing." The nurse checks her breath sounds and hears bilateral fine crackles at the base. Of what is this finding indicative?

Fluid in the alveoli

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

Forward protrusion

A nurse asks a patient to say "ninety-nine" as the nurse palpates the posterior thorax. The nurse is assessing which of the following?

Fremitus

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

Friction rub

Adventitious sounds are heard when auscultating a patient's lungs. Which of the following would the nurse do first?

Have the patient cough and then listen again

A client reports to the nurse that he experiences fatigue during the day, has difficulty sleeping lying 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 inspects the anterior thorax of a client w/ emphysema. Which change in the thorax should the nurse recognize as normal for this client?

Horizonal position to the ribs w/ a costal angle of greater than 90 degrees

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 nurse assesses the respiration pattern on a client who arrives in the ER d/t an overdose on narcotics. The nurse notes the respirations are decreased in rate & depth, and have an irregular pattern. How should the nures document this finding?

Hypoventilation

A client presents to the health care facility w/ a 2 week history of persistent dry, hacking cough, chest tightness, and shortness of breatch w/ activity. The client admits to a one-pack per day history of cigarette smoking for 20 yrs. The nurse observes a respiratory rate of 16 breaths per min, easy & regular. WHich nursing diagnosis should the nurse confirm based on these assessment data?

Impaired Gas Exchange

A client presents to health care facility w/ sudden onset of shortness of breath, inability to lie flat & a deep, wet cough. A nurse observes a respiratory rat eof 18 breaths per min, use of accessory muscles to breathe & inability to cough up secretions. Which nursing diagnosis can be confirmed w/ these data?

Ineffective Airway Clearance

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

Instruct the client to cough forcefully

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 subjective finding in a client w/ tubercolosis should a nurse recognize as an indication of the onset of pleurisy?

Knife-life pain that worrsens on inspiration

When performing a physical exam for a client w/ scoliosis, which physical characteristics should the nurse expect to find during the assessment?

Lateral deviation of the spinous process

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

Listen at each site for at least one complete respiratory cycle

A patient 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 patient's room and finds that the patient has a respiratory rate of 7 breaths/min. The patient is groggy and hard to arouse. What could be contributing to the patient's findings?

Opiates, which may cause hypoventilation

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

Palpation

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

A patient 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

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

Pleurisy

A patient 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?

Severe brain damage

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

Reasonance

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 w/ diagnosis of left lower lobe pneumonia. What change in egophony should the nurse expect to find in the lower left lobe?

Sound is louder & sounds like "A"

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

Stridor

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?

The client's upper airway may be partially obstructed.

A group of students is reviewing the vertical reference lines of the thorax. They demonstrate understanding when they identify which line as a reference line for the posterior thorax?

Vertebral line

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

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

Worse at nighttime when lying down

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

dullness