Nur 314 chapter 16 respiratory

A nurse hears adventitious lung sounds while auscultating a client's lung fields. What action should the nurse take? A. Ask the client to cough. B. Request a STAT chest x-ray. C. Notify the health care provider. D. Document the findings as normal. If adventitious lung sounds are heard on auscultation, the nurse should have the client cough to try and clear the secretions and then auscultate again. Coughing may clear the secretions and improve lung sounds. A STAT x-ray is not required because no other signs and symptoms are discussed. The nurse will need to assess the client further before contacting the health care provider. The nurse will document the findings, but adventitious lung sounds would not be considered normal

A. Ask the client to cough. If adventitious lung sounds are heard on auscultation, the nurse should have the client cough to try and clear the secretions and then auscultate again. Coughing may clear the secretions and improve lung sounds. A STAT x-ray is not required because no other signs and symptoms are discussed. The nurse will need to assess the client further before contacting the health care provider. The nurse will document the findings, but adventitious lung sounds would not be considered normal

A nurse performs a respiratory assessment on a client and notes the respiratory rate to be 8 breaths per minute. The nurse knows the proper term for this rate is what? A. Bradypnea B. Tachypnea C. Hyperventilation D. Hypoventilation

A. Bradypnea A respiratory rate of less than 10 breaths per minute is called bradypnea. Tachypnea is a respiratory rate greater than 24 breaths per minute. Hyperventilation is used to describe respirations that are increased in rate and depth. Hypoventilation is a rate that is decreased, with a decrease in depth and with an irregular pattern.

When crackles, wheezes, or rhonchi clear with a cough, which of the following is a likely etiology? A. Bronchitis B. Simple asthma C. Cystic fibrosis D. Heart failure

A. 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.

A 45-year-old male 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 Rationale: Chest pain is assumed to be heart pain and must be evaluated immediately, because heart cells die and do not regenerate. Ischemic heart pain, such as with a myocardial infarction, must be ruled out before considering another diagnosis. There is more time to treat shortness of breath, respirations of 20 breaths/min, and coughing.

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? A. Coarse crackles B. Pleural friction rubs C. Sonorous wheezes D. Sibilant wheezes

A. 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 which 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.

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

A. 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.

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

A. Funnel chest 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 backward. Intercostal bulging is noted with trapped air. Whispering pectoriloquy is identified when sounds are louder and clearer than the whispered sounds

During a comprehensive physical assessment at a home visit, a client reports chest discomfort. What is the first action of the nurse? A. Perform a focused assessment. B. Notify the health care provider immediately. C. Continue the comprehensive assessment. D. Call for an ambulance.

A. Perform a focused assessment. The nurse should immediately perform a focused assessment on the client to determine the origin of the pain, such as using COLDSPA (characteristic, onset, location, duration, severity, palliative, associated). The nurse should not contact the health care provider until the focused assessment has been completed. The nurse should not continue with the comprehensive assessment but rather perform a focused assessment of the chest pain. There is not enough information for the nurse to call an ambulance.

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? A. Pneumothorax B. Atelectasis C.Muscular weakness D. Asthma

A. 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).

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

A. Shortness of breath B. Decreased breath sounds C. Decreased oxygen saturation D. Increased tactile fremitus Rationale: 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 the tissue is consolidated, tactile fremitus is increased. The percussion sound might be dull, not hyperresonant, as a result of consolidation.

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? A. Slight kyphosis B. Inaudible posterior lung sounds C. Audible wheeze D. Asymmetrical chest expansion

A. Slight kyphosis Kyphosis (an increased curve of the thoracic spine) is common in older clients. Inaudible lung sounds, wheezing, and asymmetrical expansion are considered pathologic findings in clients of all ages.

When assessing whispered pectoriloquy, the nurse would instruct a client to do which of the following? A. Softly repeat the words "one-two-three." B. Say "ninety-nine." C. Cough each time the stethoscope is moved. D. Say the letter "e."

A. Softly repeat the words "one-two-three." Softly whispering "one-two-three" while the nurse auscultates the chest is a correct instruction for the whispered pectoriloquy test. Having the client say "ninety-nine" is used to test bronchophony. Saying the letter "e" is used to test egophony. Having the client cough is useful if an abnormal sound is heard during auscultation to determine if coughing clears the lungs.

A 17-year-old high school senior presents to the clinic in acute respiratory distress. Between shallow breaths he states he was at home finishing his homework when he suddenly began having right-sided chest pain and severe shortness of breath. He denies any recent traumas or illnesses. His past medical history is unremarkable. He doesn't smoke, but drinks several beers on the weekend. He has tried marijuana several times but denies any other illegal drugs. He is an honor student and on the basketball team. His parents are both in good health. He denies any recent weight gain, weight loss, fever, or night sweats. Examination shows a tall, thin young man in obvious distress. He is diaphoretic and breathing at a rate of 35 breaths per minute. Auscultation reveals no breath sounds on the right side of his superior chest wall. On percussion he is hyperresonant over the right upper lobe. With palpation he has absent fremitus over the right upper lobe. What disorder of the thorax or lung best describes his symptoms? A. Spontaneous pneumothorax B. Chronic obstructive pulmonary disease (COPD) C. Asthma D. Pneumonia

A. Spontaneous pneumothorax Spontaneous pneumothorax occurs suddenly, causing severe dyspnea and chest pain on the affected side. It is more common in thin young males. On auscultation of the affected side there will be no breath sounds; on percussion there is hyperresonance or tympany. There will be an absence of fremitus to palpation. Given this young man's habitus and pneumothorax, you may consider looking for features of Marfan syndrome.

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

A. 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

In palpating the chest of a client, a nurse feels a U-shaped indentation on the superior border of the manubrium. The nurse recognizes this landmark as which of the following? A. Suprasternal notch B. Sternal angle C. Acromion of the scapula D. Xiphoid process

A. Suprasternal notch The sternum, or breastbone, lies in the center of the chest anteriorly and is divided into three parts: the manubrium, the body, and the xiphoid process. The manubrium connects laterally with the clavicles (collar bones) and the first two pairs of ribs. The clavicles extend from the manubrium to the acromion of the scapula. A U-shaped indentation located on the superior border of the manubrium is an important landmark known as the suprasternal notch. A few centimeters below the suprasternal notch, a bony ridge can be palpated at the point where the manubrium articulates with the body of the sternum. This landmark, often referred to as the sternal angle (or angle of Louis), is also the location of the second pair of ribs and becomes a reference point for counting ribs and intercostal spaces.

The nurse is preparing to perform a focused respiratory assessment on a client. The nurse should be cognizant of what anatomical characteristic of the lungs? A. The right lung has three lobes, while the left lung has two lobes. B. The lungs are structurally symmetrical but functionally differently. C. The right lung is approximately one-third larger than the left lung. D. The lower lobes of both lungs are primarily located toward the anterior chest wall

A. The right lung has three lobes, while the left lung has two lobes. The right lung is made up of three lobes, whereas the left lung contains only two lobes. The sizes of the lungs are not identical but do not differ by one-third. The lower lobes of both lungs are primarily located toward the posterior surface of the chest wall.

Which statements are true concerning the location and structure of the trachea and major bronchi? A. The trachea divides or bifurcates anteriorly at the sternal angle. B. The major bronchi originate posteriorly at the spinous process of T4. C. The left main bronchus is the more vertical of the two. D. The right main bronchus is longer than the left bronchus. E. Both bronchi are equal in width.

A. The trachea divides or bifurcates anteriorly at the sternal angle. The trachea bifurcates into its mainstem bronchi at the levels of the sternal angle anteriorly and the T4 spinous process posteriorly. The right main bronchus is wider, shorter, and more vertical than the left main bronchus, which extends more laterally.

Which statement is true regarding client positioning when attempting to identify intercostal spaces during a respiratory assessment? A. Women should be assessed while in a supine position. B. Always position the client for easy access to the posterior surface of the chest. C. A prone position allows for accurate assessment of the anterior attachment of the 11th and 12th ribs. D. A man's 7th intercostal space is identified best when lying in a lateral position.

A. Women should be assessed while in a supine position. It is easier to identify intercostal spaces in women when they lie down, as the supine position displaces breast tissue across the chest. The 11th and 12th ribs, the "floating ribs," have no anterior attachments. The remaining options present incorrect statements.

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? A. chronic bronchitis. B. atelectasis. C.renal failure. D. congestive heart failure.

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

An elderly client reports a feeling of dyspnea with normal activities of daily living. What is an appropriate action by the nurse? A. Report this to the health care provider immediately B. Assess for symmetry of chest expansion C. Observe the client's respiratory rate and pattern D. Ask the client how long they have to rest between activities

B. Assess for symmetry of chest expansion It is normal for elderly clients to feel short of breath or dyspneic with activities of daily living due to age related changes of loss of elasticity, fewer functional capillaries, and loss of lung resiliency. Observing chest expansion would be appropriate assessment for a client with a pneumothorax. This finding does not need to be reported to the health care provider unless accompanied by other findings of inadequate oxygenation. Asking the client how long they need to rest between activities will not provide the nurse any objective information to differentiate the problem.

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. Kussmaul's B. Cheyne-Stokes C. Eupnea D. Tachypnea

B. Cheyne-Stokes 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 a normal respiratory rate and rhythm. Tachypnea is an increased respiratory rate.

A 62-year-old construction worker presents to the clinic reporting almost a chronic cough and occasional shortness of breath that have lasted for almost 1 year. Although symptoms have occasionally worsened with a cold, they have stayed about the same. The cough has occasional mucus drainage but never any blood. He denies any chest pain. He has had no weight gain, weight loss, fever, or night sweats. His past medical history is significant for high blood pressure and arthritis. He has smoked two packs a day for the past 45 years. He drinks occasionally but denies any illegal drug use. He is married with two children. He denies any foreign travel. His father died of a heart attack and his mother died of Alzheimer's disease. Examination reveals a man looking slightly older than his stated age. His blood pressure is 130/80 and his pulse is 88. He is breathing comfortably with respirations of 12. His head, eyes, ears, nose, and throat examinations are unremarkable. His cardiac examination is normal. On examination of his chest, the diameter seems enlarged. Breath sounds are decreased throughout all lobes. Rhonchi are heard over all lung fields. There is no area of dullness and no increased or

B. Chronic obstructive pulmonary disease (COPD) This disorder is insidious in onset and generally affects the older population with a smoking history. The diameter of the chest is often enlarged like a barrel. Percussing the chest elicits hyperresonance; during auscultation there is often distant breath sounds. Coarse breath sounds of rhonchi are also often heard. It is important to quantify this client's exercise capacity because it may affect his employment and also allows examiners to follow the progression of his disease. Clinicians must offer smoking cessation as an option.

Which of the following muscles is primarily responsible for thoracic cavity enlargement? A. Scalene B. Diaphragm C. Parasternal D. Sternomastoid

B. Diaphragm The diaphragm is the primary muscle of inspiration; when it contracts, its descent enlarges the thoracic cavity.

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. Dyspnea Rationale: 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.

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? A. Barrel chest B. Funnel chest (pectus excavatum) C. Pigeon chest (pectus carinatum) D. Thoracic kyphoscoliosis

B. 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 nurse auscultates a client's lungs and hears fine crackles. What is an appropriate action by the nurse? A. Listen again with the bell of the stethoscope B. Instruct the client to cough forcefully C. Have the client breathe through the mouth D. Assess for the use of accessory muscles

B. 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.

Which subjective finding in a client with tuberculosis should a nurse recognize as an indication of the onset of pleurisy? A. Dyspnea that is exaggerated by activity B. Knife-like pain that worsens on inspiration C. Throbbing pain that worsens on exhalation D. Dyspnea that is exaggerated by lying down

B. 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.

Which of the following occurs in respiratory distress? A. The client speaks in sentences of 10-20 words. B. Skin between the ribs moves inward with inspiration. C. Neck muscles are relaxed. D. Client torso leans posteriorly.

B. Skin between the ribs moves inward with inspiration. This description is consistent with retractions, which occur with respiratory distress. Other features include speaking in short sentences, use of accessory muscles, leaning forward to gain mechanical advantage for the diaphragm, and pursed lip breathing in which the client exhales against the lips, which are pressed together.

The results of a client's ECG and D-dimer levels suggest a pulmonary embolism. Which of the following history and examination findings would the nurse expect in light of this diagnosis? A. Relief of dyspnea with guided deep breathing B. Sudden onset of dyspnea C. History of heart failure D. Fine crackles to bases on auscultation

B. Sudden onset of dyspnea The arterial occlusion that results in pulmonary embolism normally manifests as a sudden onset of dyspnea, which deep breathing is unlikely to relieve, because part of the pulmonary arterial tree is occluded. A history of heart failure is not a notable risk factor. Absent breath sounds, not crackles, are an expected finding on auscultation.

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. Vesicular breath sounds, O2 saturation 96%, pink Rationale: 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.

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. a normal finding over the bronchi. Rationale: The trachea bifurcates at the second ICS, and bronchovesicular sounds are expected. Bronchial breath sounds are auscultated over the trachea; vesicular breath sounds are heard over the lung fields.

A client presents to the health care clinic and reports a recent onset of a persistent cough. The client denies any shortness of breath, change in activity level, or other findings of an acute upper respiratory tract illness. What question by the nurse is most appropriate to further assess the cause for the cough? A. "Have you changed your diet within the past few weeks?" B. "How much do you exercise during the week?" C. "Are you taking any medications on a regular basis?" D. "Do you feel that you are under a great deal of stress?'

C. "Are you taking any medications on a regular basis? A persistent cough without any other respiratory symptoms could be related to new medications, especially beta blockers or angiotensin converting enzyme (ACE) inhibitors, which are prescribed for hypertension. A change in diet and exercise are healthy behaviors that would not cause a persistent cough. Stress often causes shortness of breath.

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. A. Bronchovesicular B. Vesicular C. Bronchial D. Tracheal

C. 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.

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? A. Carcinoma of the lungs B. Pneumothorax C. Chronic obstructive pulmonary disease D. Tuberculosis

C. Chronic obstructive pulmonary disease An increase in the anterior posterior diameter (Barrel Chest) is seen in clients with chronic obstructive pulmonary disease. This occurs be because of air trapping in the airways that causes hyperinflation and over distention. Carcinoma of the lungs, pneumothorax, and tuberculosis do not change the chest diameter.

A client reports to the nurse that he experiences fatigue during the day, has difficulty sleeping lying down, and often wakes up at night feeling short of breath. The nurse should assess this client for other findings related to what disease process? A. Paroxysmal nocturnal dyspnea B. Sleep apnea C. Heart failure D. Upper respiratory infection

C. Heart failure Orthopnea, difficulty breathing when lying down, may be associated with heart failure. This may occur during sleep and wake the client up with severe shortness of breath. Paroxysmal nocturnal dyspnea is the term given to the severe dyspnea that wakes a person up from sleep. Sleep apnea may cause a person to feel fatigue during the day because of interrupted sleep but this syndrome is accompanied by cessation in breathing and heavy snoring and gasping sounds while sleeping. An upper respiratory infection may cause poor sleeping due to nasal congestion and cough but the client should not wake up feeling short of breath.

Which action by a nurse demonstrates proper technique for assessment of chest expansion? A. Use the ball of both hands to feel for vibrations in a symmetrical pattern across the posterior chest B. Beginning at the scapular line, percuss the intercostal spaces along both sides of the posterior chest C. Place both hands on the posterior chest at T9, press thumbs together, and then ask client to take a deep breath D. Place the stethoscope on the posterior chest wall, ask the client to take a deep breath, and observe chest rise and fall

C. Place both hands on the posterior chest at T9, press thumbs together, and then ask client to take a deep breath The correct technique for assessment of chest expansion is for the examiner to place the hands on the posterior chest wall with thumbs at the level of T9 or T110 and pressing together a small skin fold. Ask the client to take a deep breath and observe the movement of the thumbs. Using the ball of the hand to feel vibration tests for tactile fremitus. Percussion of the posterior chest wall assesses for tone. The use of a stethoscope is auscultation and this technique assesses for adventitious sounds within the lungs.

A nurse is at a family reunion playing football when a relative takes a hit to his right lateral thorax and is in pain. He asks the nurse if he has a rib fracture. The family reunion is in a very remote location. What should the nurse's next step be? A. Call an air ambulance. B. Drive him to the city (4 hours away). C. Press on his sternum and spine simultaneously. D. Examine him for tenderness over the injured area.

C. Press on his sternum and spine simultaneously. The area involved in the injury will of course be tender. Pressing in an area remote to the injury, but over the same bone that may be involved, can produce tenderness at the site of injury. This would indicate that there may be a fracture at the lateral ribs.

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? A. Left ventricular failure B. Asthma C. Pulmonary embolism D. Chronic lung disease

C. 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).

When percussing the posterior lung fields, which of the following findings is expected? A. Hyperresonance over apices B. Dullness over the lung bases C. Resonance over all lung fields D. Tympany over 11th interspace, right scapular line

C. Resonance over all lung fields All lung tissue is expected to be resonant on percussion. Hyperresonance and tympany suggest a hyperinflated lung or pneumothorax. Dullness is expected in structures below the level of the diaphragm, but dullness in the bases of the lungs themselves would be considered pathological.

A nurse is assessing a client with acute asthma. Which adventitious breath sound should the nurse expect to hear in this client? A. Fine crackles occurring late in inspiration B. Course crackles occurring from early inspiration to early expiration C. Sibilant wheezes heard primarily during expiration but may also be heard on inspiration D. Sonorous wheezes heard primarily during expiration but may be heard throughout the respiratory cycle

C. Sibilant wheezes heard primarily during expiration but may also be heard on inspiration Sibilant wheezes are often heard in cases of acute asthma or chronic emphysema. Fine crackles occurring late in inspiration are associated with restrictive diseases such as pneumonia and congestive heart failure. Course crackles that persist from early inspiration to early expiration may indicate pneumonia, pulmonary edema, or pulmonary fibrosis. Sonorous wheezes are often heard in cases of bronchitis or single obstructions and snoring before an episode of sleep apnea.

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? A. Client is hypoventilating B. Client may have overdosed on narcotics C. The pattern is expected with this condition D. These are normal Kussmaul's respirations

C. The pattern is expected with this condition Pleurisy creates difficulty in getting enough oxygen, and the body responds by increasing the respiratory effort (tachypnea) in an attempt to compensate. Hypoventilation or Cheyne-Stokes respiration would be noted with narcotic overdose. Kussmaul's respirations are associated with diabetic ketoacidosis.

The client reports severe pain when breathing in deeply. The description suggests to the nurse that the client is experiencing which respiratory condition? A. ineffective innervation of the of the parietal pleura by the phrenic nerve B. an accumulation of fluid between the lungs and the visceral pleura C. inflammation of the parietal pleura D. an increase of sensory stimulation in the visceral pleura

C. inflammation of the parietal pleura Inflammation of the parietal pleura produces pleuritic pain with deep inspiration, e.g., in pleurisy, pneumonia, and pulmonary embolism. The visceral pleura lies next to the lung, and the parietal pleura lines the inner rib cage and upper surface of the diaphragm. The visceral pleura lacks sensory nerves, but the parietal pleura is richly innervated by the intercostal and phrenic nerves.

Which accessory muscles are most important when considering inspiratory breathing needs during exercise? A. abdominal muscles B. lateral neck muscles C. sternocleidomastoids D. intercostal muscles

C. sternocleidomastoids During exercise and in certain diseases, extra work is required to breathe, and accessory muscles join the inspiratory effort. The sternocleidomastoids are the most important of these, and the scalenes may become visible. Abdominal muscles assist in expiration. Intercostals and neck muscles are involved in all respirations.

Which of the following statements relating to assessment of the lungs and thorax is most accurate? A. Hemoptysis is more common in children and adolescents than in older clients. B. Moderate to severe chest pain is associated with a cardiac etiology, while mild to moderate chest pain is most often respiratory in origin. C. Loud and very loud percussion notes denote pathological findings. D. Bronchitis is characterized by excess mucus production and chronic cough.

D. Bronchitis is characterized by excess mucus production and chronic cough. Bronchitis is marked by a chronic, productive cough that results from excess mucus production. Hemoptysis is uncommon in younger clients. It would be simplistic to differentiate cardiac from respiratory chest pain based on severity alone. Similarly, it is inaccurate to characterize all loud percussion sounds as pathological.

The nurse is performing a respiratory assessment of a client who is palliative due to severe, uncompensated heart failure. What type of respiratory pattern should the nurse anticipate? A. Biot's B. Bradypnea C. Kussmaul D. Cheyne-Stokes

D. Cheyne-Stokes Cheyne-Stokes respirations, a regular respiratory pattern alternating with periods of deep, rapid breathing followed by periods of apnea, may result from severe heart failure. Biot's respirations (irregular pattern of varied depth and rate followed by periods of apnea) may be seen with severe brain damage or meningitis. Bradypnea is a rate of less than 10/minute and can be associated with medication-induced depression of the respiratory center, diabetic coma, or neurologic damage. Kussmaul respirations are associated with diabetic ketoacidosis.

A nurse palpates for tactile fremitus and notes that the vibrations diminish towards the base of the lungs. What should the nurse recognize about this finding? A. An area of consolidation is present B. Client needs to speak louder C. Atelectasis has occurred D. Decreasing intensity is normal at the base

D. Decreasing intensity is normal at the base Fremitus should be symmetrical and easily identifiable in the upper lobes. A decrease in intensity is normal when moving towards the base of the lungs. Unequal fremitus is a result of consolidation, bronchial obstruction, air trapping, pleural effusion, or pneumothorax. Speaking louder would be necessary if no vibrations were felt at any location on the thorax.

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

D. Emergency Rationale: 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.

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? A. Pneumonia B. Pectus excavatum C. Funnel chest D. Emphysema

D. 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.

The nurse is preparing to auscultate a client's lungs after completing thoracic inspection, palpation, and percussion. How should the nurse best prepare for this assessment technique? A. Keep the client's shirt or gown in place to maintain privacy. B. Begin with the bell of the stethoscope on the client's anterior chest. C. Tell the client that you will be asking him or her to breathe as quickly and deeply as possible. D. Place the diaphragm on the client's posterior chest wall.

D. Place the diaphragm on the client's posterior chest wall. To auscultate, the nurse places the diaphragm of the stethoscope firmly and directly on the posterior chest wall, at the apex of the lung at C7. Clothing and gowns must be removed to ensure accurate assessment. The client should not be asked to breathe more rapidly than normal.

he nurse obtains a flat sound when percussing the right lower lobe of a client. What does this assessment finding indicate to the nurse? A. Healthy lung tissue B. Gastric air bubble C. Emphysema D. Pleural effusion

D. Pleural effusion When a flat sound is percussed over lung tissue, this is an indication of a pleural effusion. Resonance is the percussion sound of healthy lung tissue. The sound of a gastric air bubble is tympany. Hyperresonance is the percussion sound associated with emphysema.

While performing an assessment of a client who sustained a chest injury, which physical examination technique should the nurse use to elicit crepitus? A. Palpation B. Auscultation C. Percussion D. Inspection

A. Palpation The nurse should use the palpation technique to elicit crepitus. Crepitus is a crackling sensation that occurs when air passes through fluid or exudate. Auscultation, percussion, and inspection cannot elicit crepitus because it is air trapped into the tissue around the lungs.

What replaces resonance when fluid or solid tissue replaces air-containing lung or occupies the pleural space? A. Hyperresonance B. Dullness C. Tympany D. Chief complaint

B. Dullness Dullness replaces resonance when fluid or solid tissue replaces air-containing lung or occupies the pleural space.

Which action by a nurse demonstrates the proper sequence for auscultation of the lung fields? A. Listen at each site for at least one complete respiratory cycle B. Move from anterior to posterior on the same side C. Instruct the client to breathe in and out rapidly through the mouth D. Use the diaphragm then the bell in each location

A. Listen at each site for at least one complete respiratory cycle The client is instructed to breathe deeply though the mouth for each area as the nurse listens through inspiration and expiration. The sequence should be performed in an anterior then posterior sequence to avoid missing any areas. The bell is not used for breath sounds because it detects low pitched sound such as abnormal heart sounds.

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

A. Heart B. Lungs C. 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.

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. Tobacco smoking Rationale: Smoking is the most common cause of COPD. It is a risk that should be assessed; assistance with smoking cessation should be offered. Immune suppression increases risk of pneumonia, increased age decreases functional reserves, and occupational exposure (such as paint or asbestos) can cause toxic injury.

A 92-year-old female with a history of COPD presents with increasing shortness of breath, wheezing, no sputum, and 5-lb weight gain in 1 week. What is the most likely problem? A. Impaired breathing B. Impaired airway clearance C. Activity intolerance D. Overweight

A. Impaired breathing Rationale: Patients with COPD often have both bronchitis and emphysema symptoms that impair breathing. If they have increased secretions and mucous, their airway can become impaired, but we do not have that data so far. We also need to gather more information about her functional and activity status. A weight gain of 5 lb in 1 week is more likely due to fluid retention than diet and calorie intake.

A 62-year-old female comes to the clinic with an exacerbation of asthma. Which of the following findings indicate a diagnosis of asthma? Select all that apply. A. Increased wheezing B. Coarse rhonchi C. Fever T 38°C orally D. Oxygen saturation 90%

A. Increased wheezing D. Oxygen saturation 90% Rationale: Wheezing is associated with the airway inflammation and narrowing that accompany asthma. Pulse oximetry less than 90% is associated with asthma and is a cause for concern and reason for immediate intervention. Coarse rhonchi indicate secretions in the airway such as pneumonia and are not expected with asthma. Fever T 38°C orally is a sign of infection found with pneumonia.

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

A. It is where fluid occurs 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.

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? A. Ask the client if she has recently exerted herself. B. Report the finding to the client's primary care provider. C. Ask the client if she has smoked recently. D. Palpate the client's anterior and posterior thorax.

A. 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.

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 A. diabetic ketoacidosis. B. central nervous system injury. C. drug overdose. D. congestive heart failure.

A. diabetic ketoacidosis. Kussmaul respirations are rapid, deep, and labored. They are considered a type of hyperventilation associated with diabetic ketoacidosis.

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

B. Airway patency Consider the ABCs. Airway always assumes priority.

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? A. "When I say so, please exhale forcefully and hold the breath." B. "Say the letter 'e' and keep saying it until I tell you to stop." C. "Breathe in as deeply as you can and hold your breath until I say to stop." D. "Please say the number 'ninety-nine' for me."

D. "Please say the number 'ninety-nine' for me." To palpate for fremitus, the nurse uses the ball or ulnar edge of one hand to assess for vibrations of air in the bronchial tubes transmitted to the chest wall. As the nurse moves a hand to each area, the client is asked to say "ninety-nine." None of the other listed actions will allow the nurse to assess for vibration in the chest wall.

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? A. Emphysema B. Lung cancer C. Sleep apnea D. Bacterial infection

D. 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 finding during an assessment of a client should alert the nurse to the presence of a persistent atelectasis? A. The presence of crepitus on palpation B. A depressed sternum and cartilages C. Retraction of intercostal spaces D. Unequal expansion of the chest

D. 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.