Prep U ch 19
A hospitalized client experiences respiratory distress. The nurse should include which most appropriate client outcome in the plan of care
Airway patent, breathing quiet, denies dyspnea
While inspecting the thorax, the nurse views it from posterior and lateral positions to assess which of the following
Anteroposterior to lateral diameter
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 Farenheit. 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
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
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
When percussing the anterior chest for tone, a nurse should anticipate what tone over the majority of the lung fields
Resonance
When percussing the anterior chest for tone, a nurse should anticipate what tone over the majority of the lung fields?
Resonance
When percussing the posterior lung fields, which of the following findings is expected?
Resonance over all lung fields
The spinous process termed the vertebra prominens is in which cervical vertebra
Seventh.
A client arrives in the emergency department after a severe motor vehicle accident. The nurse observes irregular respirations of varying depth and rate followed by periods of apnea. What pathophysiological process is likely the cause of this breathing pattern?
Severe brain damage
A nurse is assessing a client with acute asthma. Which adventitious breath sound should the nurse expect to hear in this client
Sibilant wheezes heard primarily during expiration but may also be heard on inspiration
Which of the following occurs in respiratory distress
Skin between the ribs moves inward with inspiration.
A high-pitched crowing sound from the upper airway results from tracheal or laryngeal spasm and is called what
Stridor
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
Which observation confirms to the nurse that the client is experiencing a normal inspiration?
The thoracic cavity enlarges.
A new nurse on the telemetry unit is reviewing information about how to correctly read electrocardiograms. The nurse is expected to know that the PR interval represents what event
The time from firing of the sinoatrial (SA)node to the beginning of depolarization in the ventricle
The nurse is preparing to auscultate the posterior thorax of an adult female client. The nurse should
ask the client to breathe deeply through her mouth.
While assessing an adult client, the nurse observes decreased chest expansion at the bases of the client's lungs. The nurse should refer the client to a physician for possible
chronic obstructive pulmonary disease.
During the assessment of a client with a pneumothorax, what change should the nurse anticipate when auscultating for fremitus?
decreased, because a pneumothorax is a collapsed lung.
Under normal circumstances, the strongest stimulus to breathe is
hypercapnia.
The client reports severe pain when breathing in deeply. The description suggests to the nurse that the client is experiencing which respiratory condition
inflammation of the parietal pleura
The clavicles extend from the acromion of the scapula to the part of the sternum termed the
manubrium.
The thin double-layered serous membrane that lines the chest cavity is termed
parietal pleura.
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 excavatum.
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
pneumonia.
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 phrase "ninety-nine."
Which accessory muscles are most important when considering inspiratory breathing needs during exercise
sternocleidomastoids
What action by the nurse when percussing a client's chest will help maximize the resulting vibrations?
touching the chest with only the pleximeter finger
Which finding during an assessment of a client should alert the nurse to the presence of a persistent atelectasis
unequal expansion of the chest
Which terms are used to identify the lobes of the right lung? Select all that apply.
upper lobe lower lobe middle lobe
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?
Asthma
The nurse is preparing to percuss a patient's anterior chest area. Which approach will the nurse use for this assessment?
Begin above the right clavicle and percuss each section comparing the right chest with the left chest.
A nurse cares for a client admitted after falling off a ladder onto a concrete floor. The client is not arousable and pupils are fixed and dilated. When performing a respiratory assessment, the nurse recognizes which breathing pattern as normal for clients with brain damage?
Biot's
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.
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
Bronchial
Which of the following statements relating to assessment of the lungs and thorax is most accurate?
Bronchitis is characterized by excess mucus production and chronic cough.
What type of respiratory pattern would the nurse consider normal in a client with severe heart failure
Cheyne-Stokes
A client experiences increasing difficulty taking in a deep breath. For which health problem should the nurse focus when assessing this client
Chronic obstructive lung disease
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?
Chronic obstructive pulmonary disease
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
Chronic obstructive pulmonary disease (COPD)
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
Coarse crackles
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?
Coarse crackles Coarse crackles are low-pitched bubbling moist sounds that are described as separating Velcro. Fine crackles are high-pitched, short, popping sounds heard during inspiration and not cleared with coughing. Sibilant wheezes are high-pitched musical sounds. Sonorous wheezes are low-pitched snoring or moaning sounds.
What replaces resonance when fluid or solid tissue replaces air-containing lung or occupies the pleural space
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
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
The client has been admitted through the emergency department with chronic bronchitis, has elevated CO2 levels, and has been placed on O2. What priority assessment would the nurse include?
Evaluate changes in respiratory pattern and rate.
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 alveoli
A patient comes to the clinic complaining of waking during the night with sudden shortness of breath. She is diagnosed with paroxysmal nocturnal dyspnea. Before leaving the clinic, the patient asks the nurse what causes paroxysmal nocturnal dyspnea. What would be the nurse's best response?
Fluid overload from elevation of the legs
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
What would the nurse expect to hear when auscultating the lungs of a client diagnosed with pleuritis?
Friction rub
The nurse is reviewing the client's health history and notes he has pectus excavatum. The nurse would assess the client for what
Funnel chest
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?
Funnel chest (pectus excavatum)
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
Heart failure
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
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
In the mediastinum
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 in effort to open the airway, then auscultate again and note the changes
The nurse auscultates the base of the lungs to assess for what reason?
It is where fluid occurs with with pulmonary edema.
Which action by a nurse demonstrates the proper sequence for auscultation of the lung fields?
Listen at each site for at least one complete respiratory cycle
Auscultation of a 23-year-old client's lungs reveals an audible wheeze. What pathological phenomenon underlies wheezing?
Narrowing or partial obstruction of an airway passage
A nurse observes a client sitting in the tripod position. What is an appropriate action by the nurse in response to this observation
Observe for the use of accessory muscles
An elderly client reports a feeling of dyspnea with normal activities of daily living. What is an appropriate action by the nurse
Observe the client's respiratory rate and pattern
When auscultating the lungs, the nurse listens over symmetrical lung fields for which of the following?
One deep inspiration and expiration through the open mouth
While performing an assessment of a client who sustained a chest injury, which physical examination technique should the nurse use to elicit crepitus
Palpation
A triage nurse is working in the emergency department of a busy hospital. Four patients 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 patient would be the nurse's highest priority?
Patient C
What color of sputum would support the diagnosis of heart failure?
Pink
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
The nurse obtains a flat sound when percussing the right lower lobe of a patient. What does this assessment finding indicate to the nurse
Pleural effusion
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
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?"
