Ch 18

A woman in her 26th week of pregnancy states that she is "not really short of breath" but feels that she is aware of her breathing and the need to breathe. What is the nurse's best reply?

"What you are experiencing is normal. Some women may interpret this as shortness of breath, but it is a normal finding and nothing is wrong." During pregnancy, the woman may develop an increased awareness of the need to breathe. Some women may interpret this as dyspnea, even though structurally nothing is wrong. Estrogen increases relax the chest cage ligaments, causing an increase in transverse diameter. The growing fetus does increase the oxygen demand on the mother's body, but this is met easily by the increasing tidal volume (deeper breathing). Little change occurs in the respiratory rate.

The nurse is percussing over the lungs of a patient with pneumonia. The nurse knows that percussion over an area of atelectasis in the lungs would reveal: A. dullness. B. resonance. C. hyperresonance. D. tympany.

A

A patient has a long history of chronic obstructive pulmonary disease. During the assessment, the nurse is most likely to observe which of these?

An anteroposterior-to-transverse diameter ratio of 1:1 An anteroposterior-to-transverse diameter of 1:1 or "barrel chest" is seen in individuals with chronic obstructive pulmonary disease because of hyperinflation of the lungs. The ribs are more horizontal, and the chest appears as if held in continuous inspiration. Neck muscles are hypertrophied from aiding in forced respiration. Chest expansion may be decreased but symmetric. Decreased tactile fremitus occurs from decreased transmission of vibrations.

A 65-year-old patient with a history of heart failure comes to the clinic with complaints of "being awakened from sleep with shortness of breath." Which action by the nurse is most appropriate? A. Obtain a detailed history of the patient's allergies and history of asthma. B. Assess for other signs and symptoms of paroxysmal nocturnal dyspnea. C. Tell the patient to sleep on his or her right side to facilitate ease of respirations. D. Assure the patient that this is normal and will probably resolve within the next week

B

The nurse is observing the auscultation technique of another nurse. The correct method to use when progressing from one auscultatory site on the thorax to another is ____ comparison. A. posterior-to-anterior B. side-to-side C. interspace-by-interspace D. top-to-bottom

B

When assessing tactile fremitus, the nurse recalls that it is normal to feel tactile fremitus most intensely over which location?

Between the scapulae Normally, fremitus is most prominent between the scapulae and around the sternum. These are sites where the major bronchi are closest to the chest wall. Fremitus normally decreases as one progress down the chest because more tissue impedes sound transmission.

During an examination of the anterior thorax, the nurse keeps in mind that the trachea bifurcates anteriorly at the: A. suprasternal notch. B. costal angle. C. sternal angle. D. xiphoid process.

C

A patient has been admitted to the emergency department with a possible medical diagnosis of pulmonary embolism. The nurse expects to see which assessment findings related to this condition?

Chest pain that is worse on deep inspiration, dyspnea Findings for pulmonary embolism include chest pain that is worse on deep inspiration, dyspnea, apprehension, anxiety, restlessness, PaO2 less than 80, diaphoresis, hypotension, crackles, and wheezes.

During an assessment, the nurse knows that expected assessment findings in the normal adult lung include the presence of: A. absent voice sounds and hyperresonant percussion tones. B. increased tactile fremitus and dull percussion tones. C. adventitious sounds and limited chest expansion. D. muffled voice sounds and symmetrical tactile fremitus.

D

The nurse is percussing the seventh right intercostal space at the midclavicular line over the liver. Which sound should the nurse expect to hear? A. Resonance B. Tympany C. Hyperresonance D. Dullness

D

The nurse knows that a normal finding when assessing the respiratory system of an elderly adult is: A. bronchovesicular breath sounds throughout the lungs. B. increased thoracic expansion. C. a decreased anteroposterior diameter. D. decreased mobility of the thorax.

D

The primary muscles of respiration include the: A. sternomastoids and scaleni. B. trapezius and rectus abdominis. C. external obliques and pectoralis major. D. diaphragm and intercostals.

D

Which of these statements is true regarding the vertebra prominens? The vertebra prominens is: A. opposite the interior border of the scapula. B. usually not palpable in most individuals. C. located next to the manubrium of the sternum. D. the spinous process of C7.

D

The nurse is reviewing the characteristics of breath sounds. Which statement about bronchovesicular breath sounds is true? They are:

Expected near the major airways. Bronchovesicular sounds are heard over major bronchi where fewer alveoli are located: posteriorly, between the scapulae, especially on the right; anteriorly, around the upper sternum in the first and second intercostal spaces. The other responses are not correct.

A patient with pleuritis has been admitted to the hospital and complains of pain with breathing. What other key assessment finding would the nurse expect to find upon auscultation?

Friction rub A patient with pleuritis will exhibit a pleural friction rub upon auscultation. This is the sound made when pleurae become inflamed and rub together during respiration. The sound is superficial, coarse, and low-pitched, as if two pieces of leather are being rubbed together. Stridor is associated with croup, acute epiglottitis in children, and foreign body inhalation. Crackles are associated with several diseases, such as pneumonia, heart failure, chronic bronchitis, and others (see Table 18-6). Wheezes are associated with diffuse airway obstruction caused by acute asthma or chronic emphysema.

A patient has been admitted to the emergency department for a suspected drug overdose. His respirations are shallow, with an irregular pattern, with a rate of 12 per minute. The nurse interprets this respiration pattern as which of the following?

Hypoventilation Hypoventilation is characterized by an irregular, shallow pattern, and can be caused by an overdose of narcotics or anesthetics. Bradypnea is slow breathing, with a rate less than 10 respirations per minute. See Table 18-4 for descriptions of Cheyne-Stokes respirations and chronic obstructive breathing.

During auscultation of breath sounds, the nurse should use the stethoscope correctly, in which of the following ways?

Listen to at least one full respiration in each location. During auscultation of breath sounds with a stethoscope, it is important to listen to one full respiration in each location. During the examination, the nurse should monitor the breathing and offer times for the person to breathe normally to prevent possible dizziness.

During auscultation of the lungs of an adult patient, the nurse notices the presence of bronchophony. The nurse should assess for signs of which condition?

Pulmonary consolidation Pathologic conditions that increase lung density, such as pulmonary consolidation, will enhance transmission of voice sounds, such as bronchophony. See Table 18-7.

During a morning assessment, the nurse notices that the patient's sputum is frothy and pink. Which condition could this finding indicate?

Pulmonary edema Sputum alone is not diagnostic, but some conditions have characteristic sputum production. Pink, frothy sputum indicates pulmonary edema (or it may be a side effect of sympathomimetic medications). Croup is associated with a "barking" cough, not sputum production. Tuberculosis may produce rust-colored sputum. Viral infections may produce white or clear mucoid sputum.

A 70-year-old patient is being seen in the clinic for severe exacerbation of his heart failure. Which of these findings is the nurse most likely to observe in this situation?

Shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, ankle edema Heart failure often presents with increased respiratory rate, shortness of breath on exertion, orthopnea, paroxysmal nocturnal dyspnea, nocturia, ankle edema, and pallor in light-skinned individuals. A patient with rasping cough, thick mucoid sputum, and wheezing may have bronchitis. Productive cough, dyspnea, weight loss, and dyspnea are seen with tuberculosis; fever, dry nonproductive cough, and diminished breath sounds may indicate Pneumocystis jiroveci (P. carinii) pneumonia. See Table 18-8.

When considering the biocultural differences in the respiratory systems, the nurse knows that which statement is true?

The largest chest volumes are found in whites. The largest chest volumes are found, in descending order, in whites, then African-Americans, Asians, and Native Americans. Even when the shorter height of Asians is considered, their chest volume remains significantly lower than that of whites and blacks. A disproportionately large number of tuberculosis cases are reported among blacks, most of whom were born in the United States.

The nurse is auscultating the chest in an adult. Which technique is correct?

Use the diaphragm of the stethoscope held firmly against the chest. The diaphragm of the stethoscope held firmly on the chest is the correct way to auscultate breath sounds. The patient should be instructed to breathe through his or her mouth, a little deeper than usual, but not to hyperventilate.

The nurse is percussing over the lungs of a patient with pneumonia. The nurse knows that percussion over an area of atelectasis in the lungs would reveal:

dullness. A dull percussion note signals an abnormal density in the lungs, as with pneumonia, pleural effusion, atelectasis, or tumor.

During percussion, the nurse knows that a dull percussion note elicited over a lung lobe most likely results from:

increased density of lung tissue. A dull percussion note indicates an abnormal density in the lungs, as with pneumonia, pleural effusion, atelectasis, or tumor. Resonance is the expected finding in normal lung tissue.

The nurse knows that auscultation of fine crackles would most likely be noticed in:

the immediate newborn period. Fine crackles are commonly heard in the immediate newborn period as a result of the opening of the airways and clearing of fluid. Persistent fine crackles would be noticed with pneumonia, bronchiolitis, or atelectasis.

A 35-year-old recent immigrant is being seen in the clinic for complaints of a cough that is associated with rust-colored sputum, low-grade afternoon fevers, and night sweats for the past 2 months. The nurse's preliminary analysis, based on this history, is that this patient may be suffering from:

tuberculosis. Sputum is not diagnostic alone, but some conditions have characteristic sputum production. Tuberculosis often produces rust-colored sputum in addition to other symptoms of night sweats and low-grade afternoon fevers. See Table 18-8.

The nurse is reviewing the technique of palpating for tactile fremitus with a new graduate. Which statement by the graduate nurse reflects a correct understanding of tactile fremitus? "Tactile fremitus:

is caused by sounds generated from the larynx Fremitus is a palpable vibration. Sounds generated from the larynx are transmitted through patent bronchi and the lung parenchyma to the chest wall where they are felt as vibrations. Crepitus is the term for air in the subcutaneous tissues.

During palpation of the anterior chest wall, the nurse notices a coarse, crackling sensation over the skin surface. On the basis of these findings, the nurse suspect

crepitus. Crepitus is a coarse, crackling sensation palpable over the skin surface. It occurs in subcutaneous emphysema when air escapes from the lung and enters the subcutaneous tissue, as after open thoracic injury or surgery.

The nurse knows that a normal finding when assessing the respiratory system of an elderly adult is:

decreased mobility of the thorax. The costal cartilages become calcified with aging, resulting in a less mobile thorax. Chest expansion may be somewhat decreased, and the chest cage commonly shows an increased anteroposterior diameter.

The primary muscles of respiration include the:

diaphragm and intercostals The major muscle of respiration is the diaphragm. The intercostal muscles lift the sternum and elevate the ribs during inspiration, increasing the anteroposterior diameter. Expiration is primarily passive. Forced inspiration involves the use of other muscles, such as the accessory neck muscles (sternomastoids, scalene, trapezii). Forced expiration involves the abdominal muscles.

Which statement about the apices of the lungs is true? The apices of the lungs:

extend 3 to 4 cm above the inner third of the clavicles. The apex of the lung on the anterior chest is 3 to 4 cm above the inner third of the clavicles. On the posterior chest, the apices are at the level of C7.

A patient comes to the clinic complaining of a cough that is worse at night but not as bad during the day. The nurse recognizes that this may indicate:

postnasal drip or sinusitis. A cough that occurs mainly at night may indicate postnasal drip or sinusitis. Exposure to irritants at work causes an afternoon or evening cough. Smokers experience early morning coughing. Coughing associated with acute illnesses such as pneumonia is continuous throughout the day.

A mother brings her 3-month-old infant to the clinic for evaluation of a cold. She tells the nurse that he had "a runny nose for a week." When performing the physical assessment, the nurse notes that the child has nasal flaring and sternal and intercostal retractions. The nurse's next action should be to:

recognize that these are serious signs and contact the physician. The infant is an obligatory nose breather until the age of 3 months. Normally there is no flaring of the nostrils and no sternal or intercostal retraction. Marked retractions of the sternum and intercostal muscles and nasal flaring indicate increased inspiratory effort, as in pneumonia, acute airway obstruction, asthma, and atelectasis; therefore, immediate referral to the physician is warranted. These signs do not indicate heart failure, and assessment of the infant's feeding is not a priority at this time.

The nurse is observing the auscultation technique of another nurse. The correct method to use when progressing from one auscultatory site on the thorax to another is ____ comparison.

side-to-side Side-to-side comparison is most important when auscultating the chest. The nurse should listen to at least one full respiration in each location. The other techniques are incorrect.

During an examination of the anterior thorax, the nurse keeps in mind that the trachea bifurcates anteriorly at the:

sternal angle The sternal angle marks the site of tracheal bifurcation into the right and left main bronchi; it corresponds with the upper border of the atria of the heart, and it lies above the fourth thoracic vertebra on the back.

When performing a respiratory assessment on a patient, the nurse notices a costal angle of approximately 90 degrees. This characteristic is:

a normal finding in a healthy adult The right and left costal margins form an angle where they meet at the xiphoid process. Usually, this angle is 90 degrees or less. The angle increases when the rib cage is chronically overinflated, as in emphysema.

A teenage patient comes to the emergency department with complaints of an inability to breathe and a sharp pain in the left side of his chest. The assessment findings include cyanosis, tachypnea, tracheal deviation to the right, decreased tactile fremitus on the left, hyperresonance on the left, and decreased breath sounds on the left. The nurse interprets that these assessment findings are consistent with:

a pneumothorax. With a pneumothorax, free air in the pleural space causes partial or complete lung collapse. If the pneumothorax is large, then tachypnea and cyanosis are seen. Unequal chest expansion, decreased or absent tactile fremitus, tracheal deviation to the unaffected side, decreased chest expansion, hyperresonant percussion tones, and decreased or absent breath sounds are found with the presence of pneumothorax. See Table 18-8 for descriptions of the other conditions.

During an assessment, the nurse knows that expected assessment findings in the normal adult lung include the presence of:

absent voice sounds and hyperresonant percussion tones. Normal lung findings include symmetric chest expansion, resonant percussion tones, vesicular breath sounds over the peripheral lung fields, muffled voice sounds, and no adventitious sounds.

An adult patient with a history of allergies comes to the clinic complaining of wheezing and difficulty in breathing when working in his yard. The assessment findings include tachypnea, use of accessory neck muscles, prolonged expiration, intercostal retractions, decreased breath sounds, and expiratory wheezes. The nurse interprets that these assessment findings are consistent with:

asthma. Asthma is allergic hypersensitivity to certain inhaled particles that produces inflammation and a reaction of bronchospasm, which increases airway resistance, especially during expiration. Increased respiratory rate, use of accessory muscles, retraction of intercostal muscles, prolonged expiration, decreased breath sounds, and expiratory wheezing are all characteristic of asthma. See Table 18-8 for descriptions of the other conditions.

The nurse is auscultating the lungs of a patient who had been sleeping and notices short, popping, crackling sounds that stop after a few breaths. The nurse recognizes that these breath sounds are:

atelectatic crackles, and that they are not pathologic. One type of adventitious sound, atelectatic crackles, is not pathologic. They are short, popping, crackling sounds that sound like fine crackles but do not last beyond a few breaths. When sections of alveoli are not fully aerated (as in people who are asleep or in the elderly), they deflate slightly and accumulate secretions. Crackles are heard when these sections are expanded by a few deep breaths. Atelectatic crackles are heard only in the periphery, usually in dependent portions of the lungs, and disappear after the first few breaths or after a cough.

The nurse notes hyperresonant percussion tones when percussing the thorax of an infant.

consider this a normal finding. The percussion note of hyperresonance occurs normally in the infant and young child, owing to the relatively thin chest wall. Anything less than hyperresonance would have the same clinical significance as would dullness in the adult.

When assessing a patient's lungs, the nurse recalls that the left lung: A. consists of two lobes. B. is shorter than the right lung because of the underlying stomach. C. is divided by the horizontal fissure. D. consists primarily of an upper lobe on the posterior chest.

A

A 65-year-old patient with a history of heart failure comes to the clinic with complaints of "being awakened from sleep with shortness of breath." Which action by the nurse is most appropriate?

Assess for other signs and symptoms of paroxysmal nocturnal dyspnea. The patient is experiencing paroxysmal nocturnal dyspnea: being awakened from sleep with shortness of breath and the need to be upright to achieve comfort.

The nurse is assessing the lungs of an older adult. Which of these describes normal changes in the respiratory system of the older adult?

The lungs are less elastic and distensible, which decreases their ability to collapse and recoil. In the aging adult the lungs are less elastic and distensible, which decreases their ability to collapse and recoil. There is a decreased vital capacity and a loss of intraalveolar septa, causing less surface area for gas exchange. The lung bases become less ventilated, and the older person is at risk for dyspnea with exertion beyond his or her usual workload.

When assessing the respiratory system of a 4-year-old child, which of these findings would the nurse expect?

The presence of bronchovesicular breath sounds in the peripheral lung fields Bronchovesicular breath sounds in the peripheral lung fields of the infant and young child up to age 5 or 6 years are a normal finding. Their thin chest walls with underdeveloped musculature do not dampen the sound, as do the thicker chest walls of adults, so breath sounds are louder and harsher.

When inspecting the anterior chest of an adult, the nurse should include which assessment?

The shape and configuration of the chest wall Inspection of the anterior chest includes shape and configuration of the chest wall; assessment of the patient's level of consciousness, skin color and condition; quality of respirations; presence or absence of retraction and bulging of the intercostal spaces; and use of accessory muscles. Symmetric chest expansion is assessed by palpation. Diaphragmatic excursion is assessed by percussion of the posterior chest. Breath sounds are assessed by auscultation.

The nurse is assessing voice sounds during a respiratory assessment. Which of these findings indicates a normal assessment? Select all that apply.

Voice sounds are faint, muffled, and almost inaudible when the patient whispers "one, two, three" in a very soft voice. When the patient speaks in a normal voice, the examiner can hear a sound but cannot distinguish exactly what is being said. As the patient says a long "ee-ee-ee" sound, the examiner also hears a long "ee-ee-ee" sound. As a patient says "ninety-nine" repeatedly, normally, the examiner hears sound but cannot distinguish what is being said. If a clear "ninety-nine" is auscultated, then it could indicate increased lung density, which enhances transmission of voice sounds. This is a measure of bronchophony. When a patient says a long "ee-ee-ee" sound, normally the examiner also hears a long "ee-ee-ee" sound through auscultation. This is a measure of egophony. If the examiner hears a long "aaaaaa" sound instead, this could indicate areas of consolidation or compression. With whispered pectoriloquy, as when a patient whispers a phrase such as "one-two-three," the normal response when auscultating voice sounds is to hear sounds that are faint, muffled, and almost inaudible. If the examiners hears the whispered voice clearly, as if the patient is speaking through the stethoscope, then consolidation of the lung fields may exist.

The nurse is listening to the breath sounds of a patient with severe asthma. Air passing through narrowed bronchioles would produce which of these adventitious sounds?

Wheezes Wheezes are caused by air squeezed or compressed through passageways narrowed almost to closure by collapsing, swelling, secretions, or tumors, such as with acute asthma or chronic emphysema.

During an assessment of an adult, the nurse has noted unequal chest expansion and recognizes that this occurs in which situation?

When part of the lung is obstructed or collapsed Unequal chest expansion occurs when part of the lung is obstructed or collapsed, as with pneumonia, or when guarding to avoid postoperative incisional pain or atelectasis.

During auscultation of the lungs, the nurse expects decreased breath sounds to be heard in which situation?

When the bronchial tree is obstructed Decreased or absent breath sounds occur when the bronchial tree is obstructed, as in emphysema, and when sound transmission is obstructed, as in pleurisy, pneumothorax, or pleural effusion.

When assessing a patient's lungs, the nurse recalls that the left lung:

consists of two lobes The left lung has two lobes, and the right lung has three lobes. The right lung is shorter than the left lung because of the underlying liver. The left lung is narrower than the right lung because the heart bulges to the left. The posterior chest is almost all lower lobe.

When auscultating the lungs of an adult patient, the nurse notes that over the posterior lower lobes low-pitched, soft breath sounds are heard, with inspiration being longer than expiration. The nurse interprets that these are:

vesicular breath sounds and are normal in that location. Vesicular breath sounds are low-pitched, soft sounds with inspiration being longer than expiration. These breath sounds are expected over peripheral lung fields where air flows through smaller bronchioles and alveoli.