Ch. 19 Lungs

Which ribs are called the "floating ribs" because they only attach to the vertebrae?

11 and 12

The nurse is preparing to ascultate the posterior thorax of a patient with Chroic Obstructive Pulmonary Disease (COPD). The nurse knows there is a specific sequence to ascultating the posterior thorax. The nurse places the stethoscpe at how many locations on the back?

20

Right lung is made up of ___ lobes and left ____ lobes.

3, 2

Left midclavicular line at 5th intercostal

Mitral valve location

Thoracic cavity

contains resp components: trachea bronchi lungs esophagus heart great blood vessels thymus gland lymph nodes nerves

negative pressure in the lungs

inspiration

Horizontal expansion occurs as ________ lift the sternum and elevate the ribs.

intercostal muscles

diaphragmatic excursion

limited diaphragmatic descent associated with atelectasis or emphysema, pain, ascites, tumors, or pregnancy

pleura space is between the ______ and _________.

lungs, chest cavity The tiny area between the two layers of the pleura (the thin covering that protects and cushions the lungs)

Three parts of the sternum:

manubrium body xiphoid process

shortness of breath during sleep

orthopnea

Thoracic cage

outer structure of thorax -the sternum -12 pairs of ribs -12 thoracic vertebrae *provides support and protection for internal organs*

The thin double-layered serous membrane that lines the chest cavity is termed

parietal pleura.

shortness of breath that wakes a person from sleep

paroxysmal nocturnal dyspnea

crepitus

subcutaneous emphysema

visceral pleura covers...

the external surfaces of the lungs

hyperresonance

trapped air, also with emphysema or pneumothorax

fremitus

vibrations of air in bronchial tubes (normal anterior but not posterior back)

While assessing an adult patient, the nurse observes decreased chest expansion at the bases of the patient's lungs. The nurse should refer the patient to a physician for possible

chronic obstructive pulmonary disease.

-continuous coughing -cough in early morning -cough late in evening -coughs at night -weak cough

-associated with acute infection -chronic bronchial inflammation -exposure to irritants during the day -postnatal drip/sinusitis -due to weak muscles, increased thoracic wall rigidity

Sputum: -white or mucoid -yellow or green -blood in sputum (hemopysis) -rust colored -increased sputum

-common colds, viral infections -bacterial infection -serious resp condition -TB or pneumococcal pneumonia -irritants, chronic bronchitis, pulmonary abscess

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

Cheyne-Stokes Explanation: Cheyne-Stokes respirations may result from severe heart failure. Biot's respirations may be seen with severe brain damage or meningitis. Bradypnea can be associated with medication-induced depression of the respiratory center, diabetic coma, or neurologic damage. Kussmaul's respirations are associated with diabetic ketoacidosis.

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

Evidence-Based Health Promotion and Disease Prevention: COPD inlcudes which of the following components?

Health People 2020 Goals. Screening. Risk Assessment. Client Education.

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

It is where fluid occurs with with pulmonary edema.

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?

Pulmonary edema

Aspirated objects more likely to enter the _____ lung.

Right

atelectasis

a complete or partial collapse of a lung or lobe of a lung — develops when the tiny air sacs (alveoli) within the lung become deflated. Greater risk for this when patients breath shallow. (surfaces sticking together) Atelectasis is also a possible complication of other respiratory problems, including cystic fibrosis, inhaled foreign objects, lung tumors, fluid in the lung, respiratory weakness and chest injuries.

The nursing instructor teaches students the most accurate location to auscultate the right middle lobe of the lung is where? a) Anterior b) Laterally c) Medially d) Posterior

a) Anterior

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

a) Taking a deep breath

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? a) Coarse crackles b) Sibilant wheezes c) Pleural friction rubs d) Sonorous wheezes

a) coarse crackles

The nurse is preparing to auscultate the posterior thorax of a female patient. The nurse should

ask the patient to breathe deeply through her mouth.

When assessing the posterior chest, what is a starting point for counting ribs and interspaces? a) 10th rib b) 12th rib c) 6th rib d) 8th rib

b) 12th rib

When percussing the scapula of a client, which of the following would the nurse expect to hear? a) Dullness b) Flatness c) Resonance d) Hyperresonance

b) Flatness Explanation: Normally, percussion over the scapula elicits flat tones. Resonance is heard over the normal lung tissue. Dullness is heard when fluid or solid tissue replaces air in the lung. Hyperresonance is elicited in cases of trapped air, such as in emphysema or pneumothorax.

A client presents to the health care facility with a two (2) week history of persistent dry, hacky cough, chest tightness, and shortness of breath with activity. The client admits to a one (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? a) Risk for Imbalanced Nutrition b) Ineffective Airway Clearance c) Impaired Gas Exchange d) Disturbed Sleep Pattern

c) Impaired Gas Exchange Explanation: Impaired Gas Exchange related to chronic lung tissue damage secondary to chronic smoking can be confirmed because the major criteria of long standing smoking, shortness of breath, and activity intolerance. The client's cough is dry and hacky which does not meet the criteria for Ineffective Airway Clearance.

The nurse is preparing to auscultate the lung sounds of a young adult. Which sound will the nurse expect to hear over most of the patient's lungs? a) Bronchial b) Tracheal c) Vesicular d) Bronchovesicular

c) Vesicular Explanation: Vesicular breath sounds are normally heard over most of both lungs. In a young adult, this is the sound that the nurse will most likely hear when auscultating the patient's lungs. Bronchovesicular breath sounds are normally heard in the 1st and 2nd intercostal spaces anteriorly and between the scapulas posteriorly. Bronchial breath sounds are normally heard over the manubrium but may not be heard at all. Tracheal breath sounds are normally heard over the trachea in the neck.

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

c) resonance Normal lung tissue elicits a resonance tone when percussed. Hyperresonance is elicited in cases of trapped air such as in emphysema or pneumothorax. Dullness may characterize areas of increased density such as consolidation, pleural effusion, or tumor. Tympany is elicited over air filled spaces such as puffed out check or stomach bubble.

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

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

d) Bases Explanation: Careful auscultation of the bases is important because they are often the first area to collapse with atelectasis when a patient is immobile. This is also where fluid collects in a pleural effusion (outside the lungs) or with pulmonary edema (in the lungs) in heart failure.

A client complains of shortness of breath for the past few days. Examination reveals late inspiratory crackles in the lower third of the chest that were not present 1 week ago. What is the most likely explanation? a) Bronchiectasis b) COPD c) Asthma d) Heart failure

d) Heart failure Explanation: The timing of crackles within inspiration provides important clues. These late inspiratory crackles, which appeared suddenly, would be most consistent with heart failure. COPD and asthma usually produce early inspiratory crackles. Bronchiectasis, as seen in cystic fibrosis, classically produces mid-inspiratory crackles, but this is not always reliable. Interestingly, end-expiratory crackles can be heard in asthma on occasion.

A client has a history of emphysema. The nurse percusses the chest, expecting to find which of the following? a) Resonance b) Tympany c) Dullness d) Hyperresonance

d) Hyperresonance Explanation: Hyperresonance would be noted in a client with emphysema due to air trapping. Dullness is noted with fluid or solid tissue replacing air in the lung. Resonance is the normal finding on lung percussion. Tympany would be noted over areas of air, such as a gastric bubble in the stomach.

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

diabetic ketoacidosis

Vertical chest expansion occurs through contractions of the _________.

diaphragm

While assessing an adult patient, the patient tells the nurse that she has had difficulty catching her breath since yesterday. The nurse should assess the patient further for signs and symptoms of

dyspnea

positive pressure in the lungs

expiration

Thorax

extends from the base of the neck to the level of the diaphragm. Lower resp system located here: lungs distal portion of the trachea bronchi

dullness

fluid or solid tissue (tumor)

Histoplasmosis

fungal disease