Chapter 16: Thorax and Lung Assessment prep u

Identify the location where vesicular, bronchovesicular, bronchial, and tracheal lung sounds are heard (in that order).

1. over most of both lungs 2. between the scapulae 3. over the manubrium 4. over the trachea in the neck

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.

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?

Obesity, which can limit chest wall expansion and compromise breathing

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

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

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

The client reports severe pain when breathing in deeply. The description suggests to the nurse that the client is experiencing which respiratory condition?

inflammation of the parietal pleura

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 clavicles extend from the acromion of the scapula to the part of the sternum termed the

manubrium

The nurse obtains a flat sound when percussing the right lower lobe of a client. What does this assessment finding indicate to the nurse?

pleural effusion

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

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

resonance

The nurse notes that a client has the thoracic structure shown. How should the nurse document this finding?

thoracic kyphoscoliosis

The nurse is assessing a 79-year-old client's posterior thorax during a focused respiratory assessment. The nurse should attribute what assessment finding to age-related changes?

Slight kyphosis

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.

Which observation confirms to the nurse that the client is experiencing a normal inspiration?

The thoracic cavity enlarges.

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

The nurse is conducting the health interview of an adult client who has sought care because of a "wicked cough" leading to dyspnea. When trying to differentiate between pathologic lung changes and an infection as the etiology of the client's cough and resultant dyspnea, what interview question should the nurse ask?

"How long have you been experiencing your cough?"

While assessing the health of a client's respiratory system, the nurse is palpating for fremitus. What instruction should the nurse provide to the client during this component of assessment?

"Please say the number 'ninety-nine' for me.";

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

A nurse is interviewing a client who complains of dyspnea. Which of the following findings would tend to indicate an underlying cardiovascular problem in the client? Select all that apply.

Edema Angina Orthopnea

A grandmother brings her 13-year-old grandson for evaluation. She noticed last week when he took off his shirt that his breastbone seemed collapsed. He seems embarrassed and says that it has been that way for awhile. He states he has no symptoms from it and that he just tries not to take off his shirt in front of anyone. He denies any shortness of breath, chest pain, or lightheadedness on exertion. His past medical history is unremarkable. He is in sixth grade and just moved in with his grandmother after his father was transferred for a work contract. His mother died several years ago in a car accident. He states that he does not smoke and has never touched alcohol. Examination shows a teenage boy appearing his stated age. Visual examination of his chest reveals that the lower portion of the sternum is depressed. Auscultation of the lungs and heart is unremarkable. What disorder of the thorax best describes these findings?

Funnel chest (pectus excavatum) Funnel chest is caused by a depression in the lower portion of the sternum. If severe enough there can be compression of the heart and great vessels, leading to murmurs on auscultation. This is usually only a cosmetic problem, but corrective surgeries can be performed if necessary.

A client presents to the health care facility with a 2-week history of persistent dry, hacky cough, chest tightness, and shortness of breath with activity. The client admits to a 1-pack-per-day history of cigarette smoking for 20 years. The nurse observes a respiratory rate of 16 breaths per minute, easy and regular. Which nursing diagnosis should the nurse confirm based on this assessment data?

Impaired gas exchange

A client presents to the health care facility with sudden onset of shortness of breath, inability to lie flat, and a deep, wet cough. A nurse observes a respiratory rate of 18 breaths per minute, use of accessory muscles to breathe, and inability to cough up secretions. Which nursing diagnosis can be confirmed with this data?

Ineffective airway clearance

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

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

It is where fluid occurs with pulmonary edema.

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

During a physical assessment, the nurse identifies unequal chest expansion. The nurse knows this could be due to what? Select all that apply.

Pneumonia Atelectasis Trauma Pneumothorax

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

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

A client has a nursing diagnosis of ineffective airway clearance. What intervention would be most appropriate?

Teach deep breathing and coughing.

The nurse assesses shallow respirations of 28 breaths/minute in a client with pleurisy. The nurse interprets this finding as indicating which of the following?

The pattern is expected with this condition

A client with advanced chronic obstructive pulmonary disease (COPD) is very fatigued and has minimal stamina. Clustering of care has become necessary. When should the nurse auscultate this client's lungs?

When turning the client

Upon entering the examination room, the nurse observes that the client is leaning forward with his arms supporting his body weight. The nurse would suspect the presence of what condition?

chronic obstructive pulmonary disease

The nurse has assessed the respiratory pattern of an adult client. The nurse determines that the client is exhibiting Kussmaul respirations with hyperventilation. The nurse should contact the client's physician because this type of respiratory pattern usually indicates

diabetic ketoacidosis

What replaces resonance when fluid or solid tissue replaces air-containing lung or occupies the pleural space?

dullness

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 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 alveoli

The nurse is reviewing the client's health history and notes he has pectus excavatum. The nurse would assess the client for what?

funnel chest