Respiratory Mid term
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
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
During a comprehensive physical assessment at a home visit, a client reports chest discomfort. What is the first action of the nurse?
Perform a focused assessment.
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.
A client appears in the clinic with a cough that began 24 hours prior to coming to this visit. The nurse evaluates the client based on the most common cause of an acute cough, which is
viral respiratory infection
When assessing whispered pectoriloquy, what would the nurse instruct the client to do?
Softly repeat the words 'one-two-three'.
When assessing posteriorly, where would the trachea bifurcate into its mainstem bronchi?
The trachea bifurcates into its mainstem bronchi at the levels of the sternal angle anteriorly and the T4 spinous process posteriorly.
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
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
Which of the following muscles is primarily responsible for thoracic cavity enlargement?
Diaphragm
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
What would the nurse expect to hear when auscultating the lungs of a client diagnosed with pleuritis?
Friction rub
Adventitious sounds are heard when auscultating a client's lungs. Which of the following would the nurse do first?
Have the client cough, then listen again
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 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
When percussing the posterior lung fields, which of the following findings is expected?
Resonance over all lung fields
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 apex of each lung is located at the
area slightly above the clavicle.