Ch. 19 & 20 (Lungs and Cardiac)

In which location would the nurse auscultate the highest point of the lung on the anterior side of the chest? A.Seventh cervical vertebra B.3 to 4 cm above the clavicle C.Twelfth thoracic vertebra D.Six rib in the midclavicular line

3 to 4 cm above the clavicle

Which breath sounds are considered normal? SATA A. Crackles B. Wheezes C. Bronchial D. Vesicular E. Bronchovesicular

Bronchial Vesicular Bronchovesicular

After open thoracic surgery, the nurse notes a crackling sensation upon palpating the patient's chest wall. The nurse reports which condition to the provider? A. Crepitus B. Rhonchal fremitus C. Decreased fremitus D. Pleaural friction fremitus

Crepitus

Which assessment findings would the nurse identify with a barrel chest? SATA A. Thorax is symmetric al in the elliptical shape. B. Chest appears as if held in continuous inspiration. C. Ribs appear to be horizontal in relation to the spine. D. Scapulae are placed symmetrically in each hemithorax. E Anteroposterior diameter is equal to the transverse diameter.

Chest appears as if held in continuous inspiration. Ribs appear to be horizontal in relation to the spine. Anteroposterior diameter is equal to the transverse diameter.

Which physiologic mechanism causes the first heart sound? A. Closing of the mitral valve B. Filling of the ventricle C. Closing of the aortic valve D. Closing of the pulmonic valve

Closing of the mitral valve

Which assessment finding would the nurse expect for a patient with chronic respiratory disease? A. Cutaneous angiomas B. Restlessness and anxiousness C. Clubbing of the distal phalanges D. Significant drowsiness

Clubbing of the distal phalanges

The nurse auscultates the patient's respirations and notes breath sounds similar to opening Velcro. Which term would the nurse use to document this finding? A. Fine crackles B. Coarse crackles C. Pleural friction rub D. High-pitched wheeze

Coarse crackles

The patient with pathologic S 3 heart sound has which condition? A. A stenotic heart valve B. Coronary artery disease C. Vigorous atrial contraction D. Decreased compliance of the ventricles

Decreased compliance of the ventricles

A client with emphysema experiences shortness of breath and uses pursed-lip breathing and accessory muscles of respiration. The nurse determines that the cause of the dyspnea is for which reason? A. Spasm of the bronchi that traps the air B. Increase in the vital capacity of the lungs C. Too rapid expulsion of air from the bronchioles D. Difficulty in expelling the air trapped in the alveoli

Difficulty in expelling the air trapped in the alveoli

Which description of hypercapnia is correct? A. Beginning of rapid, deep breathing B. Presence of slow, shallow breathing C. Decreased oxygen level in the blood D. Increased carbon dioxide in the blood

Increased carbon dioxide in the blood

Name 3-5 sxs of right-sided heart failure.

JVD peripheral edema

Which landmark is correct for the nurse to use when auscultating the mitral valve? A. Left fifth intercostal space, midaxillary line B. Left fifth intercostal space, midclavicular line C. Left second intercostal space, sternal border D. Left fifth intercostal space, sternal border

Left fifth intercostal space, midclavicular line

Which term is used to describe the pacemaker of the heart? A. Bundle of His B. Purkinje fibers C. Sinoatrial node D. Atrioventricular node

Sinoatrial node

Name 3-5 sxs of left-sided heart failure.

pulmonary edema eventual right sided heart failure

Which finding would the nurse expect upon auscultating the lung sounds of a patient with heart failure? A. Occasional wheezing B. Crackles in the lung bases C. Crackles over upper lobes D. Bilateral expiratory wheezes

Crackles in the lung bases

Where would the nurse place the stethoscope to assess the patient's bronchial breath sounds? A. Over the trachea and the larynx B. Over the peripheral lung fields C. Posteriorly between the scapulae D. Anteriorly near the upper sternum

Over the trachea and the larynx

The nurse instructs a student nurse to palpate the patient's carotid artery. Which action made by the student nurse needs correction? A. Having the patient sit during the exam B. Palpating both carotid arteries at once C. Refraining from excess vagal stimulation D. Not compressing the carotid sinuses

Palpating both carotid arteries at once

Which data regarding chest palpation findings is accurate? Data/Condition/ Intensity of Vibrations 1. Pleural effusion - increased vibrations 2. Pneumonia - Decreased vibrations 3. Pneumothorax - Absence of vibrations 4. Lung hyperinflation - absence of vibrations

Pneumothorax - Absence of vibrations

Which assessment finding may be present in a patient with atherosclerosis? A. Low-pitched rumbling B. Presence of bruit sound C. Weak contraction of the ventricles D. Unilateral distention of the external jugular veins

Presence of bruit sound

Which heart sound occurs because of the closure of the semilunar valves? A. First heart sound (S1) B. Second heart sound (S2) C. Third heart sound (S3) D. Fourth heart sound (S4)

Second heart sound (S2)

After auscultating the chest, how will the nurse document findings of bilateral, high-pitched, continuous whistling sounds heard during each expiration? A. Crackles B. Wheezes C. Rhonchus D. Pleural friction rub

Wheezes

During auscultation of the heart, where would the nurse expect the first heart sound (S1) to be the loudest? A. Base of the heart B. Apex of the heart C. Left lateral border D. Right lateral border

Apex of the heart

A young adult patient reports difficulty in breathing. Upon inspection, the patient is cyanotic, using accessory neck muscles to breathe, and audibly wheezing. Palpation reveals decreased tactile fremitus with hyperresonant sounds on percussion. Normal breath sounds are distant and hard to hear because of wheezing. The nurse suspects further testing will lead to which diagnosis? A. Asthma B. Bronchitis C. Pneumonia D. Atelectasis

Asthma

Which technique would the nurse use to assess for tactile fremitus? A. By placing the finger tips on the sides of the neck B. By placing the thumb on the spinous process of the patient C. By placing warmed hands side ways on the posterolateral chest wall D. By placing the palmar base of one hand to touch the patient's chest

By placing the palmar base of one hand to touch the patient's chest

Which assessment finding indicates abnormally elevated pressures in the right side of the heart? A. Pulmonary congestion B. Pulmonary hypertension C. Distended neck veins and abdomen D. Systolic blood pressure higher than diastolic blood pressure

Distended neck veins and abdomen

While auscultating the chest, the nurse asks the patient to phonate along "ee-ee-ee-ee" sound. Through the stethoscope, the nurse hears along "aaaaa" sound. Which term would the nurse to document this assessment? A. Egophony B. Bronchophony C. Sonorous wheezing D. Whispered pectoriloquy

Egophony

The middle-aged patient reports, " I can't get my breath when I walk. "Upon assessment, the nurse notes that the patient has a barrel chest and is using the accessory muscles to breathe. The patient's respiratory rate is 28. On palpation, there is a limited expansion and decreased tactile fremitus. Percussion yields hyperresonant sounds. On auscultation, prolonged expiration, scattered wheezes, and rhonchi are present. Which disorder would the nurse suspect? A. Atelectasis B. Pneumonia C. Emphysema D. Pleural effusion

Emphysema

The patient reports coughing up pink, frothy sputum. The nurse reports suspicion of which condition to the provider? A. TB B. Viral infection C. Bacterial infection D. Pulmonary edema

Pulmonary edema

When assessing a client, the nurse auscultates a murmur at the second left intercostal space (ICS) along the sternal border. Which valve does this sound reflect? A. Aortic B. Mitral C. Pulmonic D. Tricuspid

Pulmonic

The nurse observes a client with chronic obstructive pulmonary disease (COPD) breathing rapidly and using accessory muscles of respiration. The nurse auscultates the lungs and hears crackles and wheezes. What action should the nurse take? A. Encourage the client to take slow, deep breaths and administer 5 L/min oxygen per nasal cannula. B. Place the client in a side-lying position and perform chest physiotherapy using clapping and vibration. C. Raise the head of the bed to a high-Fowler position and administer 2 L/min oxygen per nasal cannula. D. Assist the client in assuming a position of comfort and perform postural drainage.

Raise the head of the bed to a high-Fowler position and administer 2 L/min oxygen per nasal cannula.

Which respiratory assessment finding would the nurse report as abnormal for an adult patient? A. Ratio of pulse to respirations is 4:1 B Respiratory depth is 500 to 800mL. C. Respiratory rate is 24 to 30per minute. D. Respiratory pattern appears to be even.

Respiratory rate is 24 to 30per minute

Which statement describes a lift with respect to the cardiovascular system? A. Vibration felt over the apex of the heart B. Sustained thrust of the ventricle of the heart C. Exaggerated pulse felt on the carotid artery D. Murmur over the second right intercostals pace during diastole

Sustained thrust of the ventricle of the heart

Which statement describes a thrill? A. Palpable vibration in the chest B. Apical impulse C. Associated with a venous hum D. Sustained thrust of the ventricle of the heart

Sustained thrust of the ventricle of the heart

Which observations would the nurse expect in a patient with chronic obstruction pulmonary disease COPD? SATA A. The neck muscles appear to be hypertrophied from over work. B The spinous processes appear as if they are in a straight line. C. There are no major changes in the color of the patient's skin. D. The patient leans forward with the arms against the knees. E. The anteroposterior and transverse diameter are both equal.

The neck muscles appear to be hypertrophied from over work. The patient leans forward with the arms against the knees. The anteroposterior and transverse diameter are both equal.

Which observations would the nurse expect in a patient with chronic obstruction pulmonary disease (COPD)? Select all that apply. A. The neck muscles appear to be hypertrophied from overwork B. The spinous processes appear as if they are in a straight line C. There are no major changes in the color of the patient's skin D. The patient leans forward with the arms against the knees E. The anteroposterior and transverse diameter are both equal

The patient leans forward with the arms against the knees The anteroposterior and transverse diameter are both equal The neck muscles appear to be hypertrophied from overwork

Which finding would the nurse associate with Cheyne-Stokes respiration? A. The respiration cycle length is variable. B. The breathing period lasts for 10 seconds. C. There are periods of apnea between normal breaths D. Three to four respirations are followed by apnea

There are periods of apnea between normal breaths

The presence of which finding in the cardiac assessment of a middle-aged patient would the nurse consider to be abnormal? A. Apical impulse B. Venous hum C. Jugular venous pulse D. Third heart sound

Third heart sound