Health Assessment Exam 3 (Respiratory)

The thoracic cavity contains which of the following organs? Select all that apply. A.) Most of the esophagus B.) Pancreas C.) Lungs D.) Stomach E.) Heart

E. Heart, C. Lungs, and A. Most of the Esophagus 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.

When assessing a patient with atelectasis, what assessment findings are expected? Choose all that apply. A.) Shortness of breath B.) Decreased breath sounds C.) Decreased oxygen saturation D.) Increased tactile fremitus E.) Hyperresonance

A, B, C, and D. With atelectasis, the lung tissue has collapsed, which leads to less tissue for oxygenation. Consequently, the oxygen saturation is low, breath sounds are decreased, and the patient is short of breath. Because this tissue is consolidated, tactile fremitus is increased. The percussion sounds might be dull, not hyperresonant, as a result of consolidation.

What are the signs of hypoxia? Select all that apply. A.) Respiratory rate > 30 B.) Cyanosis C.) Increased level of consciousness D.) Retractions E.) Use of accessory muscles to breathe F.) Oxygen saturation of 90%

A, B, D, and E. A decreased level of consciousness, respiratory rate > 30 breaths/min, oxygen saturation less then 90%, cyanosis, retractions, and use of accessory muscle may indicate hypoxia.

A client has a nursing diagnosis of impaired gas exchange related to alveolar-capillary membrane changes. What interventions are appropriate in this situation? Select all that apply. A.) Administer oxygen B.) Facilitate deep breathing C.) Increase fluids D.) Use an incentive spirometer E.) Reduce fever

A, B, and D. Interventions that are appropriate for client with impaired gas exchange related to alveolar-capillary membrane changes include administering oxygen, teaching deep breathing, and encouraging use of incentive spirometry or an inhaler. Neither increasing fluids nor reducing fever is an appropriate intervention with this nursing diagnosis

The nurse is percussing over the lungs of a patient with pneumonia. The nurse knows that percussion over an area of atelectasis in the lungs will reveal: A.) Dullness B.) Tympany C.) Resonance D.) Hyperresonance

A. A dull percussion note signals an abnormal density in the lungs, as with pneumonia, pleural effusion, atelectasis, or tumor.

A 70-year-old patient is being seen in the clinic for severe exacerbation of his heart failure. Which of these findings is the nurse most likely to observe in this patient? A.) Shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, and ankle edema B.) Rasping cough, thick mucoid sputum, wheezing, and bronchitis C.) Productive cough, dyspnea, weight loss, anorexia, and tuberculosis D.) Fever, dry nonproductive cough, and diminished breath sounds

A. A person with heart failure often exhibits increased respiratory rate, shortness of breath on exertion, orthopnea, paroxysmal nocturnal dyspnea, nocturia, ankle edema, and pallor in light-skinned individuals. A patient with rasping cough, thick mucoid sputum, and wheezing may have bronchitis. Productive cough, dyspnea, weight loss, and dyspnea indicate tuberculosis; fever dry nonproductive cough, and diminished breath sounds may indicate Pneumocystis jiroveci (dm. carinii) pneumonia.

The nurse is listening to the breath sounds of a patient with severe asthma. Air passing through narrowed bronchioles would produce which of these adventitious sounds? A.) Wheezes B.) Bronchial sounds C.) Bronchophony D.) Whispered pectoriloquy

A. Wheezes are caused by air squeeze or compressed though passageways narrowed almost to closure by collapsing, swelling, secretions, or tumors, such as with acute asthma or chronic emphysema.

An adult patient with a history of allergies comes to the clinic complaining of wheezing and difficulty when working in his yard. The assessment findings include tachypnea, the use of accessory neck muscles, prolonged expiration, intercostal retractions, decreased breath sounds, and expiratory wheezes. The nurse interprets that these assessment findings are consistent with: A.) Asthma B.) Atelectasis C.) Lobar pneumonia D.) Heart failure

A. Asthma is allergic hypersensitivity to certain inhaled particles that produces inflammation and a reaction of bronchospasm, which increased airway resistance, especially during expiration. An increased respiratory rate, the use of accessory muscles, a retraction of the intercostal muscles, prolonged expirations, decreased breath sounds, and expiratory wheezing are all characteristic of asthma.

A 45-year-old man has been admitted to the hospital with suspicion of PE. Which of the following symptoms should the nurse report to the primary health practitioner immediately? A.) Chest pain B.) Shortness of breath C.) Respirations 20 breaths/min D.) Productive cough

A. Chest pain is assumed to be heart pain and must be evaluated immediately. Ischemic heart pain, such as with a myocardial infraction, must be ruled out before considering another diagnosis.

A respiratory pattern that gradually becomes faster and deeper than normal, then slower, alternating with periods of apnea is known as which respiratory pattern? A.) Cheyne-Stokes B.) Tachypnea C.) Kussmaul's D.) Eupnea

A. Cheyne-Stokes respirations are described as respirations that gradually become faster and deeper than normal, then slower, alternating with periods of apnea. This pattern can be drug-induced, normal in frail elderly people while sleeping, or a sign of impending death. Kussmaul's respiratory pattern is described as faster and deeper respirations without pauses. Eupnea is normal respiratory rate and rhythm. Tachypnea is an increased respiratory rate.

During auscultation of the lungs, the nurse expects decreased breath sounds to be heard in which situation? A.) When the bronchial tree is obstructed B.) When adventitious sounds are present C.) In conjunction with whispered pectoriloquy D.) In conditions of consolidation, such as pneumonia

A. Decreased or absent breath sounds occur when the bronchial tree is obstructed, as in emphysema, and when sound transmission is obstructed, as in pleurisy, pneumothorax, or pleural effusion.

A nurse in the operating room has a client who just underwent gastric bypass surgery and weighs 243 kilograms (534.6 pounds). Upon extubation, the client's oxygen saturation drops to 84% and the client has difficulty catching her breath. What could be causing these problems? A.) Obesity, which can limit chest wall expansion and compromise breathing B.) A progressive loss of muscle function C.) Pain, which is inhibiting the client's ability to breathe D.) Anesthesia, which is causing the client to be sleepier than usual

A. Extreme obesity can limit chest wall expansion (and thus compromise breathing). Progressive loss of muscle function is related to disease such as muscular dystrophy, not obesity. Pain and anesthesia would not be causes of decreased oxygen saturation and breathing difficulty.

When assessing tactile fremitus, the nurse recalls that it in normal to feel tactile fremitus most intensely over which location? A.) Between the scapulae B.) Third intercostal space, MCL C.) Fifth intercostal space, midaxillary line (MAL) D.) Over the lower lobes, posterior side

A. Normally, fremitus is most prominent between the scapulae and around the sternum. These sites are where the major bronchi are closet to the chest wall. Fremitus normally decreased as one progresses down the chest because more tissue impedes sound transmission.

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.) Pulmonary edema B.) Infection C.) Atelectasis D.) Tuberculosis

A. Pink, frothy sputum may indicate pulmonary edema. Tuberculosis sputum may be rusty color and green sputum may indicate an infection. The client with atelectasis may not be coughing any sputum up.

The nurse is observing the auscultation technique of another nurse. The correct method to use when progressing from one auscultatory site on the thorax to another is ........ comparison. A.) Side-to-side B.) Top-to-bottom C.) Posterior-to-anterior D.) Interspace-by-interspace

A. Side-to-side comparison is most important when auscultating the chest. The nurse should listen to at least one full reparation in each location.

A high-pitched crowing sound from the upper airways results from tracheal or laryngeal spasm and is called what? A.) Stridor B.) Crackles C.) Wheezes D.) Rales

A. 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 attention. Crackles, wheezes, and rales are adventitious breath sounds heard upon auscultation of the lungs.

When assessing a patient's lungs, the nurse recalls that the left lung: A.) Consists of two lobes B.) Id divided by the horizontal fissure C.) Primarily consists of an upper lobe on the posterior chest D.) Is shorter than the right lung because of the underlying stomach

A. The left lung has two lobes, and the right lung has three lobes. The right lung is shorter than the left lung because of the underlying liver. The left lung is narrower than the right lung because the heart bulges to the left. The posterior chest is almost all lower lobes.

The primary muscles of respiration include the: A.) Diaphragm and intercostals B.) Sternomastoid and scaleni C.) Trapezii and rectus abdominis D.) External obliques and pectoralis major

A. The major muscle of respiration is the diaphragm. The intercostal muscles lift the sternum and elevate the ribs during inspiration, increasing the anteroposterior diameter. Expiration is primarily passive. Forced inspiration involves the use of other muscles, such as the accessory neck muscles sternomastoid, scaleni, and trapezii muscles. Forced expiration involves the abdominal muscles.

Which of these statements is true regarding the vertebra prominens? The vertebra prominens is: A.) The spinous process of C7 B.) Usually nonpalpable in most individuals C.) Opposite the interior border of the scapula D.) Located next to the manubrium of the sternum

A. The spinous process of C7 is the vertebra prominens and is the most prominent bony spur protruding at the base of the neck. Counting ribs and intercostal spaces on the posterior thorax is difficult because of the muscles and soft tissue. The vertebra prominens is easier to identify and is used as a starting point in counting thoracic process and identifying landmarks on the posterior chest.

A 62-year-old woman comes to the clinic with an exacerbation of asthma. Which of the following findings indicate worsening status of her asthma. A.) Increased wheezing B.) Sustained rhonchi C.) Decreased respirations D.) Oxygen saturation 94%

A. Wheezing is associated with the airway inflammation and narrowing that accompany asthma. Bronchial rhonchi indicate secretions in the airway such as pneumonia and are not expected with asthma. increased respirations are expected with decreased oxygenation. Pulse oximetry less than 92% is cause for concern.

An adult client comes to the clinic. The client is pale and diaphoretic, the respiratory rate is 30 breaths/minute. Coarse crackles are noted in all lung fields. The client has smoked for 40 years. Why is this client at increased risk for pneumonia? Select all that apply. A.) Increased respiratory rate which impacts the amount of oxygen the client is able to inhale. B.) Decreased ability to cough up secretions because of weakened chest muscles. C.) At great risk for "stiff lungs," which are harder to ventilate, because of his age. D.) Increased risk for COPD because of years of smoking. E.) Pooling of secretions because of decreased function of the cilia.

B, E, D, and C. Decreased function of the cilia leads to the pooling of secretions in the lungs. Weaker chest muscles also decrease the older person's ability to cough up secretions. Thick, pooled secretions increase risks for pneumonia. The option pertaining to increased respiratory rate is a distracter to the question.

A patient comes to the clinic complaining of a cough that us worse at night but not as bad during the day. The nurse recognizes that this cough may indicate: A.) Pneumonia B.) Postnasal drip or sinusitis C.) Exposure to irritants at work D.) Chronic bronchial irritation from smoking

B. A cough that primarily occurs at night may indicate postnasal drip or sinusitis. Exposure to irritants at work causes an afternoon or evening cough. Smokers experience early morning coughing. Coughing associated with acute illness such as pneumonia is continuous throughout the day.

The nurse auscultates the base of the lungs to assess for what reason? A.) It best reflects the health of the lungs B.) It is where fluid occurs with pulmonary edema C.) It indicates early infection

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

When the nurse assesses a 78-year-old patient with pneumonia, what is the priority assessment. A.) Breath sounds B.) Airway patency C.) Respiration rate D.) Percussion sounds

B. Consider the ABCs. Airway always assumes priority.

Which assessment findings would indicate that inhaled bronchodilators have been effective? A.) Expiratory wheezing, O2 saturation 94%, pallor B.) Vesicular breath sounds, O2 saturation 96%, pink C.) Bronchial breath sounds. O2 saturation 100%, erythema D.) Crackles, O2 saturation 90%, circumoral cyanosis

B. If bronchodilators are effective, assessment findings would indicate adequate gas exchange. Abnormal findings include wheezing, low oxygen saturation, pallor, bronchial breath sounds, erythema, crackles, and cyanosis.

When caring for a client with chronic shortness of breath, fatigue is an issue. How might the nurse limit fatigue and still gather assessment information needed for daily care? A.) Spread care throughout the shift to allow rest periods B.) Cluster care during times when the client is more rested C.) Use shorter assessments D.) Use more than one nurse to gather assessment data

B. In cases in which fatigue limits the collection of assessment data, the nurse should consider clustering care. Spreading care throughout the shift does not focus on times when the client feels capable of handling activity. More than one nurse addresses potential nurse fatigue, not client fatigue. Shorter assessment might not allow the nurse to gather crucial data.

During an assessment of an adult, the nurse has noted unequal chest expansion and recognizes that this occurs in which situation? A.) In an obese patient B.) When part of the lung is obstructed or collapsed C.) When bulging of the intercostal spaces is present D.) When accessory muscles are used to augment respiratory effort

B. Inequal chest expansion occurs when part of the lung is obstructed or collapsed, as with pneumonia, or when guarding to avoid postoperative incisional pain.

When the nurse assesses a client with respiratory symptoms. which of the following complaints should be evaluated first? A.) Chest soreness B.) Dyspnea C.) Cough D.) Sputum

B. Shortness of breath is observed during the initial contact with the patient. These data assist in determining the acuity of the problem. Chest tenderness with palpation will be assessed during the history; sputum and lung sounds are assessed during the physical assessment.

Which statement about the apices of the lungs is true? The apices of the lungs: A.) Are at the level of the second rib anteriorly B.) Extent 3 to 4 cm above the inner third of the clavicles C.) Are located at the sixth rib anteriorly and the eighth rib laterally D.) Rest of the diaphragm at the fifth intercostal space in the midclavicular line (MCL)

B. The apex of the lung p the anterior chest is 3 to 4 cm above the inner third of the clavicles. On the posterior chest, the apices are at the level of C7

The nurse knows that a normal finding when assessing the respiratory system of an older adult is: A.) Increased thoracic expension B.) Decreased mobility of the thorax C.) Decreased anteroposterior diameter D.) Bronchovesicular breath sounds throughout the lungs

B. The costal cartilages become calcified with aging, resulting in less mobile thorax. Chest expansion may be somewhat decreased, and the chest cage commonly shows an increased anteroposterior diameter.

A mother brings her 3-month-old infant to the clinic for evaluation of a cold. She tells the nurse that he has had a runny nose for a week. When performing the physical examination, the nurse notes that the child has nasal flaring and sternal intercostal retractions. The nurse next action should be to: A.) Assure the mother that these signs are normal symptoms of a cold B.) Recognize that these are serious signs, and contact the physician C.) Ask the mother if the infant has had trouble with feedings D.) Perform a complete cardiac assessment before these signs are probably indicative of early heart failure

B. The infant is an obligatory nose breather until the age of 3 months. Normally, no flaring of the nostrils and no sternal or intercostal retractions occurs. Significant retractions of the sternum and intercostal muscles and nasal flaring indicate increased inspiratory effort, as in pneumonia, acute airway obstruction, asthma, and atelectasis; therefore, immediate referral to the physician is warranted. These signs do not indicate heart failure, and an assessment of the infants feeding not a priority at this time.

During an examination of the anterior thorax, the nurse is aware that the trachea bifurcates anteriorly at the: A.) Costal angle B.) Sternal angle C.) Xiphoid process D.) Suprasternal notch

B. The sternal angle marks the site of tracheal bifurcation into the right and left main bronchi; it corresponds with the upper borders of the atria of the heart, and it lies above the fourth thoracic vertebra on the back.

The nurse auscultates bronchovesicular breath sounds in the second ICS near the sternum. The nurse interprets this as: A.) A normal finding over the trachea B.) A normal finding over the bronchi C.) An abnormal finding over the lung D.) An abnormal finding over the trachea

B. The trachea bifurcates at the second intercostal space, and bronchovesicular sounds are expected. Bronchial breath sounds are auscultated over the traches; vesicular breath sounds are heard over the lung fields.

A teenage patient comes to the emergency department with complaints of an inability to breathe and a sharp pain in the left side of his chest. The assessment findings include cyanosis, tachypnea, tracheal deviation to the right, decreased tactile fremitus on the left, hyperresonance on the left, and decreased breath sounds on the left. The nurse interprets that these assessment findings are consistent with: A.) Bronchitis B.) Pneumothorax C.) Acute pneumonia D.) Asthmatic attack

B. With a pneumothorax, free air in the pleural space cause partial or complete lung collapse. If the pneumothorax is large, then tachypnea and cyanosis are evident. Unequal chest expansion, decreased or absent tactile fremitus, tracheal deviation to the unaffected side, decreased chest expansion, hyperresonant percussion tones, and decreased or absent breath sounds are found with the presence of pneumothorax.

During auscultation of the lungs of an adult patient, the nurse notices the presence of bronchophony. This nurse should assess for signs of what condition? A.) Airway obstruction B.) Emphysema C.) Pulmonary consolidation D.) Asthma

C. Pathologic conditions that increase lung density, such as pulmonary consolidation, will enhance the transmission of voice sounds, such as bronchophony.

During a physical assessment, the nurse identifies inequal chest expansion. The nurse knows this could be due to what? Select al that apply. A.) Atelectasis B.) Trauma C.) Pneumonia D.) Pneumothorax E.) Emphysema

C, A, B, and D. Decreased chest excursion is seen with emphysema. Asymmetrical chest movements may be due to pneumonia, pneumothorax, trauma or atelectatis.

A client has a nursing diagnosis of ineffective airway clearance related to fatigue and inability to cough effectively as evidenced by respiratory rate and dyspnea. What outcome would be appropriate for this client? A.) The client demonstrated accurate cough and deep breathing techniques B.) Teach the client cough and deep breathing techniques to preform every 2 hours C.) Breath sounds return to baseline within 1 week D.) The client increases force and depth of breath to clear secretions

C. An appropriate outcome is that breath sounds return to baseline within 1 week. Teaching coughing and deep breathing is an intervention, not an outcome. A client with fatigue would not be expected to demonstrate accurate cough and deep breathing techniques. Increasing the force and depth of breath to clear secretions is not an appropriate action.

The nurse is reviewing the characteristics of breath sounds. Which statement about bronchovesicular breath sounds is true? Bronchovesicular breath sounds are: A.) Musical in quiality B.) Usually caused by a pathologic disease C.) Expected near the major airways D.) Similar to bronchial sounds except shorter in duration

C. Bronchovesicular breath sounds are heard over major bronchi where fewer alveoli are located posteriorly between the scapulae, especially on the right; and anteriorly, around the upper sternum in the first and second intercostal spaces.

When assessing the respiratory system of a 4-year-old, which of these findings would the nurse expect? A.) Crepitus palpated at the costochondral junctions B.) No diaphragmatic excursion as a result of a child's decreased inspiratory volume C.) Presence of bronchovesicular breath sounds in the peripheral lung fields D.) Irregular respiratory pattern and a respiratory rate pf 40 breaths per minute at rest

C. Bronchovesicular breath sounds in the peripheral lung fields of the infant and young child up to age 5 or 6 years are normal findings. Their thing chest walls with underdeveloped musculature do not dampen the sound, as do the thicker chest walls of adult; therefore, breath sounds are loud and harsh.

A woman in her 26th week of pregnancy states that she is "not really short of breath" but feels that she is aware of her breathing and the need to breathe. What is the nurse's best reply? A.) "The diaphragm becomes fixed during pregnancy, making it difficult to take in a deep breath." B.) "The increase in estrogen levels during pregnancy often causes a decrease in the diameter of the rib cage and makes it difficult to breathe." C.) "What you are experiencing is normal. Some women may interpret this as shortness of breath, but it is a normal finding and nothing is wrong." D.) "This increased awareness of the need to breathe is normal as the fetus grows because of the increased oxygen demand on the mother's body, which results in an increased respiratory rate."

C. During pregnancy, the woman may develop an increased awareness of the need to breathe. Some women may interpret this as dyspnea, although structurally nothing is wrong. Increased in estrogen relax the chest cage ligaments, causing an increase in the transverse diameter. Although the growing fetus increases the oxygen demand on the mother body, this increased diameter is easily met by the increasing tidal volume (deeper breathing). Little changes occur in the respiratory rate.

The nurse knows that auscultation of fine crackles would most likely be noticed in: A.) A healthy 5-year-old child B.) A pregnant woman C.) The immediate newborn period D.) Association with a pneumothorax

C. Fine crackles are commonly heard in the immediate newborn period as a result of the opening of the airways and a clearing of fluid. Persistent fine crackles would be noticed with pneumonia, bronchiolitis, or atelectasis.

The nurse is auscultating the chest in an adult. Which technique is correct? A.) Instructing the patient to take deep, rapid breaths B.) Instructing the patient to breathe in and out through his or her nose C.) Firmly holding the diaphragm of the stethoscope against the chest D.) Lightly holding the bell of the stethoscope against the chest to avoid friction

C. Firmly holding the diaphragm of the stethoscope against the chest is the correct way to auscultate breath sounds. The patient should be instructed to breathe through his or her mouth, a little deeper than usually, but not to hyperventilate.

The nurse is reviewing the technique of palpating for tactile fremitus with a new graduate. Which statement by the graduate reflects a correct understanding of tactile fremitus? A.) Is caused by moisture in the alveoli B.) Indicates that air is present in the subcutaneous tissue C.) Is caused by sounds generated from the larynx D.) Reflects the blood flow through the pulmonary arteries

C. Fremitus is a palpable vibration. Sounds generated from the larynx are transmitted through patent bronchi and the lung parenchyma to the chest wall where they are felt as vibrations. Crepitus is the term for air in the subcutaneous tissues.

During an assessment, the nurse knows that expected assessment findings in the normal adult lung include the presence of: A.) Adventitious sounds and limited chest expansion B.) Increased tactile fremitus and dull percussion tones C.) Muffled voice sounds and symmetric tactile fremitus D.) Absent voice sounds and hyperresonant percussion tones

C. Normal lung findings include symmetric chest expansion, resonant percussion tones, vesicular breath sounds over the peripheral lung fields, muffled voice sounds, and no adventitious sounds.

The nurse is reviewing the client's health history and notes he has pectus excavatum. The nurse would assess the client for what? A.) Pectoriloquy B.) Intercostal bulging C.) Funnel chest D.) Pigeon chest

C. Pectus excavatum or funnel chest occurs when the sternum and adjacent cartilages are significantly sunken inward or dented. Pigeon chest or pectus carinatum occurs when the sternum protrudes backwards. Intercoastal bulging is noted with trapped air. Whispering pectoriloquy is identified when sounds are louder and clearer than the whispered sounds.

Which of the following factors is the most significant risk factor for COPD? A.) Increased age B.) Immune suppression C.) Tobacco smoking D.) Occupational exposure

C. Smoking is the most common cause of COPD. It is a risk that should be assessed; assistance with smoking cessation should be offered.

A 35-year-old recent immigrant is being seen in the clinic for complaints of a cough that is associated with rust-colored sputum, low-grade afternoon fevers, and night sweats for the past 2 months. The nurse's preliminary analysis, based on this history, is that this patient may be suffering from: A.) Bronchitis B.) Pneumonia C.) Tuberculosis D.) Pulmonary edema

C. Sputum is not diagnostic alone, but some conditions have characteristics sputum production. Tuberculosis often produces rust-colored sputum in addition to other symptoms of night sweats and low-grade afternoon fevers.

A 65-year-old patient with a history of heart failure comes to the clinic with complaints of being awakened from sleep with shortness of breath. Which action by the nurse is most appropriate? A.) Obtaining a detailed health history of the patients' allergies and a history of asthma B.) Telling the patient to sleep on his or her right side to facilitate ease of respirations C.) Assessing for other signs and symptoms of paroxysmal nocturnal dyspnea D.) Assuring the patient that paroxysmal nocturnal dyspnea is normal and will probably resolve within

C. The patient is experiencing paroxysmal nocturnal dyspnea being awakened from sleep with shortness of breath and the need to be upright to achieve comfort.

When performing a respiratory assessment on a patient, the nurse notices a costal angle of approximately 90 degrees. This characteristic is: A.) Observed in patients with kyphosis B.) Indicative of pectus excavatum C.) A normal finding in a healthy adult D.) An expected finding in a patient with a barrel chest.

C. The right and left costal margins from an angle where they meet at the xiphoid process. Usually, this angle is 90 degrees or less. The angle increases when they rib cage is chronically overinflated, as in emphysema.

When auscultating the lungs of an adult patient, the nurse notes that low-pitched, soft breath sounds are heard over the posterior lower lobes, with inspiration being lower the expirations. The nurse interprets that these sounds are: A.) Normally auscultated over the trachea B.) Bronchial breath sounds and normal in that location C.) Vesicular breath sounds and normal in that location D.) Bronchovesicular breath sounds and normal in that location

C. Vesicular breath sounds are low-pitched, soft sounds with inspiration being longer than expiration. These breath sounds are expected over the peripheral lung fields where air flows through smaller bronchioles and alveoli.

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.) Fluid in the bronchus B.) No fluid present C.) Fluid in the alveoli D.) Fluid in the bronchioles

C. 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 it the bronchioles or bronchus or the absence of fluid in the lungs.

During percussion, the nurse knows that a dull percussion note elicited over a lung lobe most likely result from: A.) Shallow breathing B.) Normal lung tissue C.) Decreased adipose tissue D.) Increased density of lung tissue

D. A dull percussion note indicates an abnormal density in the lungs, as with pneumonia, pleural effusion, atelectasis, or a tumor. Resonance is the expected finding in normal lung tissue.

A patient has a long history of chronic obstructive pulmonary disease (COPD). During the assessment, the nurse will most likely observe which of these? A.) Unequal chest expansion B.) Increased tactile fremitus C.) Atrophied neck and trapezius muscles D.) Anteroposterior-to-transverse diameter ratio of 1:1

D. An anteroposterior-to-transverse diameter ratio of 1:1 or barrel chest is observed in individuals with COPD because of hyperinflation of the lungs. The ribs are more horizontal, and the chest appears as if held in continuous inspiration. Neck muscles are hypertrophied from aiding in forced respiration. Chest expansion may be decreased but symmetric. Decreased tactile fremitus occurs from decreased transmission of vibrations.

A nurse is receiving report from the night shift about four clients. Which client would the nurse see first? A.) A 23-year-old woman who has a mountain biking accident in which she suffered a neck fracture and now has numbness and tingling in her right arm. B.) A 29-year-old woman with a history of drug abuse and a heart rate of 124 beats/min. C.) A 57-year-old woman who has surgery yesterday for a small bowel obstruction with possible wound dehiscence. D.) A 64-year-old man with COPD who is short of breath and has a respiratory rate of 32 breaths/min.

D. Decreased level of consciousness, respiratory rate about 30 breaths/min, cyanosis, retractions, and use of accessory muscles may indicate hypoxia (a medical emergency).

A client in the ED tells the nurse she us having difficulty breathing at rest. What term would the nurse use to document this finding? A.) Tachypnea B.) Anxiety C.) Shortness of breath D.) Dyspnea

D. 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.

An adult client is brought to the ED by her daughter. The client is cyanotic; her pulse is 117 beats/min, respirations 36 breaths/min, blood pressure 100/64, and oxygen saturation 82%. What is the first nursing action? A.) Call a code B.) Leave the client and daughter so as not to overexcite them C.) Start an 18-guage IV D.) Administer oxygen

D. If a client has acute shortness of breath, immediate assessments include respiratory rate, pulse, blood pressure, and oxygen saturation. The lungs are auscultated. Simultaneously, oxygen is administered, and inhalers may be given. If the client is in bed, the head of the bed is elevated to reduce the effect of gravity. Because anxiety increased the work of breathing, the nurse's role is to stay with and to calm the client. Conversations should be limited while the nurse implements interventions to improve oxygenation.

The nurse is assessing the lungs of an older adult. Which of these changes are normal in the respiratory system of an older adult? A.) Severe dyspnea is experienced on exertion, resulting from changes in the lungs B.) Respiratory muscle strength increases to compensate for a decreased vital capacity C.) Decrease in small airway closure occurs, leading to problems with atelectasis D.) Lungs are less elastic and distensible, which decreased their ability to collapse and recoil

D. In the aging adult, the lungs are less elastic and distensible, which decreases their ability to collapse and recoil. Vital capacity is decreased, and a loss of intra-alveolar septa occurs, causing less surface area for gas exchange. The lung bases become less ventilated, and the older person is at risk for dyspnea with exertion beyond his or her usual workload.

When inspecting the anterior chest of an adult, the nurse should include which assessment? A.) Diaphragmatic excursion B.) Symmetric chest expansion C.) Presence of breath sounds D.) Shape and configuration of the chest wall

D. Inspection of the anterior chest includes shape and configurations of the chest wall; assessment of the patient's level of consciousness and the patient skin color and condition; quality of respirations; presence or absence of retraction and bulging of the intercostal spaces; and use of accessory muscles. Symmetric chest expansion is assessed by palpation. Diaphragmatic excursion is assessed by percussion of the posterior chest. Breath sounds are assessed by auscultation.

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.) Anesthesia, from surgery that morning B.) Nothing, this is normal following surgery C.) Opiates, which may cause hyperventilation D.) Opiates, which may cause hypoventilation

D. 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 92-year-old woman with a history of COPD presents with increasing shortness of breath, decreased lung sounds in the bases, increased ankle edema, and 5-lb weight gain in 1 week. What is the most likely problem? A.) Impaired gas exchange B.) Ineffective airway clearance C.) Activity intolerance D.) Excess fluid volume

D. Patients with chronic obstructive pulmonary disease (COPD) often retain fluid because of the increased workload of the heart that the disease imposes. Fluid accumulates in the bases and peripheral parts of the lungs, leading to increased shortness of breath and weight gain.

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.) Rales B.) Asthma C.) Pneumonia D.) Pleurisy

D. 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 in respiration nor does asthma. Rales are an adventitious breath sound, not a respiratory condition.

A 3-year-old boy is brought to the emergency room with stridor, nasal flaring, intercostal and supraclavicular retractions, and a respiratory rate 40 breaths/min. What type of situation is this? A.) Stable B.) Acute C.) Urgent D.) Emergency

D. Stridor indicates upper airway obstruction and is considered an emergency. Because it is accompanied in this case by retractions and tachypnea, a rapid response may be indicated.

The nursing instructor taches students the most accurate location to auscultate the right middle lobe of the lung is where? A.) Medially B.) Laterally C.) Posterior D.) Anterior

D. The right middle lobe is best auscultated using the anterior approach. Only a small portion can be auscultated laterally.