Thorax and Lungs PrepU

Which terms are used to identify the lobes of the right lung? Select all that apply. base lobe major lobe upper lobe middle lobe lower lobe

upper lobe middle lobe lower lobe

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

Bronchitis is characterized by excess mucus production and chronic cough.

The nurse is performing the technique shown. What is the nurse assessing? Tissue consolidation Chest expansion Tactile fremitus Breath sounds

Chest expansion

What type of respiratory pattern would the nurse consider normal in a client with severe heart failure? Cheyne-Stokes Biot's Bradypnea Kussmaul

Cheyne-Stokes

Upon inspection of a client's chest, a nurse observes an increase in the ratio of anteroposterior to transverse diameter. The nurse recognizes this as a finding in which disease process? Tuberculosis Pneumothorax Chronic obstructive pulmonary disease Carcinoma of the lungs

Chronic obstructive pulmonary disease

Which observation confirms to the nurse that the client is experiencing a normal inspiration? The diaphragm is seen relaxing. The abdominal wall is pushed inward. The thoracic cavity enlarges. Air can be heard moving out of the tracheobronchial tree.

The thoracic cavity enlarges.

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? Pleurisy Asthma Pneumonia Rales

Pleurisy

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? Pneumonia Rales Asthma Pleurisy

Pleurisy

When auscultating a client's lungs, the nurse hears a loud popping sound that clears when the client coughs. What sound is this client most likely demonstrating? wheezes coarse crackles rhonchi fine crackles

coarse crackles

The nurse assesses an adult client's thoracic area and observes a markedly sunken sternum and adjacent cartilages. The nurse should document the client's: pectus carinatum. pectus excavatum. pectus diaphragm. pectus thorax.

pectus excavatum.

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: bronchitis. tuberculosis. asthma. pulmonary edema.

tuberculosis.

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? "Are you taking any medications on a regular basis?" "Do you feel that you are under a great deal of stress?' "How much do you exercise during the week?" "Have you changed your diet within the past few weeks?"

"Are you taking any medications on a regular basis?"

During a health history of the respiratory system, a client reports experiencing a cough for several months. Which questions would the nurse ask for more information about the duration of this symptom? (Select all that apply.) "Does it occur at rest or with exercise?: "Does this occur at a particular time of day?" "Is it continuous or intermittent?" "Do you cough up mucus or phlegm?" "Does it wake you at night?"

"Does it occur at rest or with exercise?: "Does this occur at a particular time of day?" "Is it continuous or intermittent?" "Does it wake you at night?"

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

A 64-year-old man with COPD who is short of breath and has a respiratory rate of 32 breaths/min

While inspecting the thorax, the nurse views it from posterior and lateral positions to assess which of the following? Anteroposterior to lateral diameter Position of the trachea Curvature of the cervical spine Inflammation of the costochondral junction

Anteroposterior to lateral diameter

A 21-year-old college senior presents to the clinic reporting shortness of breath and a nonproductive nocturnal cough. She states she used to feel this way only with extreme exercise, but lately she has felt this way continuously. She denies any other upper respiratory, gastrointestinal, and urinary symptoms and says she has no chest pain. Her past medical history is significant only for seasonal allergies, for which she takes a nasal steroid spray; she takes no other medications. She has had no surgeries. Her mother has allergies and eczema; her father has high blood pressure. She is an only child. She denies smoking and illegal drug use but drinks three to four alcoholic beverages per weekend. She is a junior in finance at a local university and has recently started a job as a bartender in town. On examination she is in no acute distress. Temperature is 98.6, blood pressure is 120/80, pulse is 80, and respirations are 20. Head, eyes, ears, nose, and throat examinations are essentially normal. Inspection of her anterior and posterior chest shows no abnormalities. On auscultation of her chest, there is decreased air movement and a high-pitched whistling on expiration in all lobes. Percussion reveals resonant lungs. Which disorder of the thorax or lung does this presentation best describe? Chronic obstructive pulmonary disease (COPD) Asthma Spontaneous pneumothorax Pneumonia

Asthma

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? Bacterial infection Lung cancer Emphysema Sleep apnea

Bacterial infection

Adventitious sounds related to atelectasis and pulmonary edema are first evident when auscultating what area of the respiratory system? Bases Bronchi Apices Trachea

Bases

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. Vesicular Tracheal Bronchial Bronchovesicular

Bronchial

Which type of breath sounds should a nurse anticipate on auscultation of the right lower lobe in a client with right lower lobe pneumonia? Diminished Bronchial Vesicular Bronchovesicular

Bronchial

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 decreased fremitus. What thorax or lung disorder is most likely causing his symptoms? Asthma Chronic obstructive pulmonary disease (COPD) Spontaneous pneumothorax Pneumonia

Chronic obstructive pulmonary disease (COPD)

When auscultating a client's lungs, the nurse hears a sound like Velcro being pulled apart over the client's right middle lobe. How should the nurse document this finding? Fine crackles Sonorous wheeze Sibilant wheeze Coarse crackles

Coarse crackles

The nurse demonstrates appropriate technique when using what part of the hand to assess for fremitus in a client? Fist Palmar base Pads of fingers Dorsal hand surface

Palmar base

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

Dullness

A client in the ED tells the nurse that she is having difficulty breathing at rest. What term would the nurse use in documenting this finding? Dyspnea Anxiety Tachypnea Shortness of breath

Dyspnea

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 the bronchioles No fluid present Fluid in the alveoli Fluid in the bronchus

Fluid in the alveoli

A nurse asks a client to say "ninety-nine" while palpating the posterior thorax. The nurse is demonstrating effective technique in assessing for what respiratory characteristic? Fremitus Egophony Bronchophony Chest expansion

Fremitus

What would the nurse expect to hear when auscultating the lungs of a client diagnosed with pleuritis? Friction rub Stridor Sibilant wheeze Decreased breath sounds

Friction rub

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

Heart Most of the esophagus Lungs

During a health history, a client tells the nurse that "I can't breathe well at night when I'm lying down". The client also reports an interrupted sleep pattern caused by waking up with trouble breathing and a nagging cough. Considering the client's reports, what medical condition should the nurse's assessment be focused on? Bronchitis Heart failure induced orthopnea Pneumonia-related dyspnea Tuberculosis-related cough

Heart failure induced orthopnea

A client has a history of emphysema. The nurse percussing the client's chest expects to hear what characteristic sound? Resonance Tympany Dullness Hyperresonance

Hyperresonance

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? Risk for Imbalanced Nutrition Impaired Gas Exchange Disturbed Sleep Pattern Ineffective Airway Clearance

Impaired Gas Exchange

A nurse is auscultating the bronchi of a client. The nurse understands that the bronchi are located in which of the following locations in the body? At the level of the 8th rib on the right mid-clavicular line In the mediastinum At the base of the lungs At the level of the 12th rib on the left scapular line

In the mediastinum

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 Ineffective Breathing Pattern Impaired Gas Exchange Risk for Respiratory Infection

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 Assess for the use of accessory muscles Have the client breathe through the mouth Listen again with the bell of the stethoscope

Instruct the client to cough forcefully

Auscultation of a 23-year-old client's lungs reveals an audible wheeze. What pathological phenomenon underlies wheezing? Fluid in the alveoli Decreased compliance of the lungs Blockage of a respiratory passage Narrowing or partial obstruction of an airway passage

Narrowing or partial obstruction of an airway passage

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

Observe the client's respiratory rate and pattern

When auscultating the lungs, the nurse listens over symmetrical lung fields for which of the following? Two full breaths in through the mouth and out through the nose One quiet full inspiration through pursed lips Two full breaths every 10 seconds through the nose One deep inspiration and expiration through the open mouth

One deep inspiration and expiration through the open mouth

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? Opiates, which may cause hypoventilation Anesthesia, from surgery that morning Opiates, which may cause hyperventilation Nothing, this is normal following surgery

Opiates, which may cause hypoventilation

A triage nurse is working in the emergency department of a busy hospital. Four clients have recently been admitted. Patient A has an arrhythmia diagnosed as atrial fibrillation; Patient B is in chronic congestive heart failure; Patient C is assessed and found to have a probable pulmonary embolism; Patient D complains of chest pain relieved by nitroglycerin and rest. Which client would be the nurse's highest priority? Patient D Patient C Patient A Patient B

Patient C

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 Beginning at the scapular line, percuss the intercostal spaces along both sides of the posterior chest Place the stethoscope on the posterior chest wall, ask the client to take a deep breath, and observe chest rise and fall Use the ball of both hands to feel for vibrations in a symmetrical pattern across the posterior chest

Place both hands on the posterior chest at T9, press thumbs together, and then ask client to take a deep breath

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

Pleural effusion

A 47-year-old receptionist comes to the office with fever, shortness of breath, and a productive cough with golden sputum. She says she had a cold last week and her symptoms have only worsened despite using over-the-counter cold remedies. She denies any weight gain, weight loss, or cardiac or gastrointestinal symptoms. Her past medical history includes type 2 diabetes for 5 years and high cholesterol level. She takes an oral medication for both diseases. She has had no surgeries. She denies tobacco, alcohol, or drug use. Her mother has diabetes and high blood pressure. Her father passed away from colon cancer. Examination reveals a middle-aged woman appearing her stated age. She looks ill and her temperature is elevated at 101 degrees Fahrenheit. Her blood pressure and pulse are unremarkable. Her head, eyes, ears, nose, and throat examination are unremarkable except for edema of the nasal turbinates. On auscultation she has decreased air movement and coarse crackles are heard over the left lower lobe. There is dullness on percussion, increased fremitus during palpation, and egophony and whispered pectoriloquy on auscultation. What disorder of the thorax or lung best describes her symptoms? Pneumonia Spontaneous pneumothorax Chronic obstructive pulmonary disease (COPD) Asthma

Pneumonia

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

Resonance

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 Muscular weakness Atelectasis Asthma

Pneumothorax

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? Infection Tuberculosis Atelectasis Pulmonary edema

Pulmonary edema

The spinous process termed the vertebra prominens is in which cervical vertebra? Seventh. Sixth. Fifth. Eighth.

Seventh.

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

Sibilant wheezes heard primarily during expiration but may also be heard on inspiration

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

Stridor

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? Acromion of the scapula Sternal angle Xiphoid process Suprasternal notch

Suprasternal notch

A person with a barrel chest has a problem doing what? Breathing at a normal respiratory rate Coughing Taking a deep breath Expelling excess oxygen

Taking a deep breath

The staff educator from the hospital's respiratory unit is providing a public educational event. The educator is talking about health promotion activities for people with respiratory diseases or those who are at high risk for respiratory complications. What would the educator include in the presentation? Teaching strategies to reduce complications of existing diagnoses Reinforcing the need for a high-calorie diet Showing participants how to diagnose respiratory problems Encouraging adequate rest

Teaching strategies to reduce complications of existing diagnoses

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

Unequal expansion of the chest

The apex of each lung is located at the: area slightly above the clavicle. level of the diaphragm. left oblique fissure. level of the sixth rib.

area slightly above the clavicle.

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: chronic bronchitis. congestive heart failure. renal failure. atelectasis.

chronic bronchitis.

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: drug overdose. diabetic ketoacidosis. congestive heart failure. central nervous system injury.

diabetic ketoacidosis.

Under normal circumstances, the strongest stimulus to breathe is: hypoxemia. hypocapnia. pH changes. hypercapnia.

hypercapnia.

After percussing a client's lung fields the nurse suspects a client has a chronic lung disease. What sound did the nurse hear to make this clinical determination? hyperresonance dull resonance flat

hyperresonance

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

inflammation of the parietal pleura

While assessing an adult client's lungs during the postoperative period, the nurse detects coarse crackles. The nurse should refer the client to a physician for possible: bronchitis. pleuritis. pneumonia. asthma.

pneumonia.

The nurse is assessing a client's thorax. Which structures should the nurse identify as articulating anteriorly with the 10th rib? the spine previous rib cartilages nothing sternum

previous rib cartilages

While assessing the thoracic area of an adult client, the nurse plans to auscultate for voice sounds. To assess bronchophony, the nurse should ask the client to: repeat the letter "A." whisper the phrase "one-two-three." repeat the phrase "ninety-nine." repeat the letter "E."

repeat the phrase "ninety-nine."