Chapter 18: Thorax and Lungs

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

Chest pain that is worse on deep inspiration, dyspnea

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

Listen to at least one full respirations in each location

A 70-year-old patient is being seen in the clinic for sever 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, andle adema

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

Use the diaphragm of the stethoscope held firmly against the chest.

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

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 recongnizes that these breath sounds are:

atelectatic crackles, and that they are not pathologic.

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.

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

postnasal drip or sinusitis

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

A woman in her 26th week of pregnancy states that she is "not really short of breath" but feels that she is aware ofher 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."

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

The shape and configuration of the chest wall.

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

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

sternal angle

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

the immediate newborn period

Which of these statements is true regarding the vertebra prominens? The vertebra prominens is:

the spinous process of C7

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.

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 soudns?

Wheezes

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

When part of the lung is obstructed or collapsed

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

When the bronchial tree is obstructed

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

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

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

between the scapulae

The nurse notes hyperresonant percussion tones when percussing the thorax of an infant. The nurse's best action would be to:

consider this a normal finding

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

consists of two lobes

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 suspects:

crepitus

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

decreased mobility of the thorax

The primary muscles of respiration include the:

diaphragm and intercostals

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

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

expected near the major airways

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

increased density of lung tissue

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

muffled voice sounds and symmetrical tactile fremitus

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 nurses next action should be to:

recognize that these are serious signs and contact the physician

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

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.

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

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 dyspea.

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

Friction rub

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

Hypoventilation

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 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.

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

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

Pulmonary consolidation

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

Pulmonary edema