HA- Resp

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 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 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. Labored and noisy breathing is often seen with severe asthma or chronic bronchitis.

The nurse is assessing a client's respiratory rate and rhythm during the beginning of a shift. The client's rate is 29 breaths per minute. How should the nurse respond to this assessment finding?

Ask the client if she has recently exerted herself. Respiratory rate is highly dependent on recent exertion and activity. This variable should be ruled out before making a referral. Palpation is unlikely to ascertain the cause of the increased respiratory rate. Smoking is a possible cause, but activity is more likely.

While assessing an adult client, the client tells the nurse that she "has had difficulty catching her breath since yesterday." The nurse should assess the client further for signs and symptoms of

infection. Sudden onset of dyspnea is associated with viral or bacterial infections.

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. 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.

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. 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

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 auscultates very loud, high-pitched lung sounds that are equal in length over a client's anterior chest. Which area did the nurse most likely hear these sounds?

trachea Tracheal sounds are very loud and harsh with inspiratory and expiratory sounds equal in length, over the trachea in the neck. Bronchial sounds are louder and higher in pitch and are heard over the manubrium. Bronchovesicular sounds are heard between the scapula. Vesicular sounds are heard over most of the lung fields.

A client has sustained a brain stem injury and is being treated in the intensive care unit. What would the nurse need to consider when assessing this client's respiratory status?

The client will have a loss of involuntary respiratory control. The brain stem contains the medulla and the pons, which control involuntary respiratory effort. The negative response to stimuli is unrelated to the client's respiratory function. Cheyne-Stokes respirations are an abnormal pattern of rhythmic breathing. The client's breathing will not be characterized by increased effort.

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 nurse is palpating a Caucasian client's chest as part of a routine assessment. Which of the following findings would the nurse expect in this client because of his race?

A larger thorax and greater lung capacity The size of the thorax, which affects pulmonary function, differs by race. Compared with African Americans, Asians, and Native Americans, adult Caucasians have a larger thorax and greater lung capacity. A costal angle greater than 90 degrees is an indicator of long-standing hyperinflation of the lungs, as in emphysema. Pectus carinatum is a forward protrusion of the sternum causing the adjacent ribs to slope backward (often referred to as pigeon chest). Barrel-chest configuration results in a more horizontal position of the ribs and costal angle of more than 90 degrees. This often results from long-standing emphysema.

The nurse's auscultation of a client's lung fields reveals the presence of a wheeze. The nurse should recognize that this adventitious sound results from what pathophysiological process?

Air passing through constricted passageways Wheezes appear when air passes through constricted passages. Wheezes are not the result of diversion of air to the bronchi, increased turbulence, or air entering the pleural space.

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 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.

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

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.

Which subjective finding in a client with tuberculosis should a nurse recognize as an indication of the onset of pleurisy?

Knife-like pain that worsens on inspiration Knife-like pain that worsens on inspiration is a characteristic finding that indicates pleurisy in the client. Pleurisy or a pleural rub is caused when the inflamed pleural surface comes in contact with each other on inspiration. Dyspnea is exaggerated by activity but is not a characteristic feature. Clients with pleurisy do not have throbbing pain. Dyspnea in pleurisy is not exaggerated by lying down.

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 Lung auscultation is performed for one full breath over symmetrical lung fields. The client should be encouraged to breathe deeply through an open mouth.

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

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

Sound is louder and sounds like "A" To perform egophony, the nurse asks the client to repeat the letter "E" while listening with the stethoscope. Over normal lung tissue, the sound will be soft and muffled but the letter should be distinguishable. In areas of consolidation, such as pneumonia, the letter "E" will sound louder and sound like the letter "A". Bronchophony uses the words "Ninety nine". Whispered pectoriloquy uses the phrase "1-2-3".

Which of the following is consistent with good percussion technique?

Strike the pleximeter over the distal interphalangeal joint. Percussion takes practice to master. Most struggle initially with keeping the wrist and hand relaxed. Other challenges include removing the plexor quickly and keeping the other fingers off the chest wall. These can dampen the sound that the examiner is trying to obtain. The ideal target for the plexor is the distal interphalangeal joint.

It has become apparent that there is not a lifetime immunity to pertussis for those who received the childhood DPT vaccine.

True

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

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.

Which pleural membrane lines the chest cavity?

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.

An adult client visits the clinic and tells the nurse that he has been "spitting up rust-colored sputum." The nurse should refer the client to the physician for possible

tuberculosis.

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

Anteroposterior to lateral diameter 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.

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.

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 These characteristics are consistent with bronchial breath sounds. Be alert for these because they may occur elsewhere and indicate pneumonia or other pathology. The current explanation for this phenomenon is that fluid carries the sound from the trachea very well to the chest wall. This same explanation explains 'ee' to & 'aa' changes, whispered pectoriloquy, bronchophony, and others in which high-frequency sounds, normally blocked by air-filled alveoli, could be transmitted to the chest wall.

When crackles, wheezes, or rhonchi clear with a cough, which of the following is a likely etiology?

Bronchitis Adventitious sounds that clear with cough are usually consistent with bronchitis or atelectasis. The other conditions would not have findings that cleared with a cough.

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 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.

While examining a client, the nurse observes the client's chest to be barrel shaped. The nurse would interpret this as indicating which of the following?

Emphysema A barrel chest is often seen in emphysema because of hyperinflation of the lungs. A change in chest shape would be rare with pneumonia. Pectus excavatum or funnel chest is a congenital malformation.

When percussing the scapula of a client, what would the nurse expect to hear?

Flatness Normally, percussion over the scapula elicits flat tones. Resonance is heard over the normal lung tissue. Dullness is heard when fluid or solid tissue replaces air in the lung. Hyperresonance is elicited in cases of trapped air such as in emphysema or pneumothorax.

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 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.

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.

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

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

Instruct the client to cough forcefully When auscultating crackles in the lung fields, the nurse should instruct the client to cough forcefully in an effort to open the airways. Then the nurse should auscultate again and note any changes. Lung sounds should be listened to with the diaphragm because they are high pitched sounds. The bell is used for low pitched sounds such as abnormal heart sounds. Breathing through the mouth lets the air in quicker but will not clear the airways. Use of accessory muscles is seen with respiratory distress.

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

It is where fluid occurs with with pulmonary edema. Auscultation of the bases is important because it is where fluid occurs with pulmonary edema and the location for fluid accumulation with a pleural effusion. It does not indicate infection or health of the lungs.

A client is diagnosed with pulmonary edema, and the nurse is performing a rapid assessment prior to treatment. The nurse would be most concerned about what assessment finding related to the client's sputum?

Pink and frothy Pink sputum is associated with pulmonary edema. 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.

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 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?

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.

The nurse is caring for a client who is 48 hours postop from the repair of a fractured hip. She has a sudden onset of dyspnea without pain. What disease process would the nurse suspect?

Pulmonary embolism Risk factors for pulmonary embolism include postpartum or postoperative periods, prolonged bed rest, congestive heart failure, chronic lung disease, fractures of hip or leg, and deep venous thrombosis (often not clinically apparent).

The nurse is assessing the various lobes of the client's lungs. To gather accurate data, the nurse must assess which lobe anteriorly?

Right middle lobe The right middle lobe of the lung does not extend to the posterior side of the thoracic wall and thus must be assessed from the anterior surface alone. The other lung lobes can be assessed anteriorly and posteriorly.

An adult client has been diagnosed with bronchitis. What would the nurse most likely hear on auscultation?

Sonorous wheezes Sonorous wheezes are often heard with bronchitis. Sibilant wheezes are often heard with acute asthma or chronic emphysema. Fine crackles, heard on late inspiration, suggest restrictive disease, such a pneumonia or heart failure. Coarse crackles may indicate pneumonia, pulmonary edema, or pulmonary fibrosis.

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