Chapter 19 - Q & A

Question 1

Which of these statements is true regarding the vertebra prominens?

a. It is the spinous process of C7.
b. It is nonpalpable in most individuals.
c. It is opposite the interior border of the scapula.
d. It is located next to the manubrium of the sternum.

Answer 1

ANS: A
The spinous process of C7 is the vertebra prominens and is the most prominent bony spur protruding at the base of the neck. Counting ribs and intercostal spaces on the posterior thorax is difficult because of the muscles and soft tissue. The vertebra prominens is easier to identify and is used as a starting point in counting thoracic processes and identifying landmarks on the posterior chest. The vertebra prominens is not opposite the interior border of the scapula or next to the manubrium of the sternum. Instead, the vertebra prominens is the spinous process of C7. It is the most prominent bony spur protruding at the base of the neck, thus, it is easy to identify and palpate. Because counting ribs and intercostal spaces on the posterior thorax is difficult due to the number of muscles and soft tissue, the vertebra prominens is used as a starting point in counting thoracic processes and identifying landmarks on the posterior chest.

Question 2

When performing a respiratory assessment on a patient, the nurse notices a costal angle of approximately 90 degrees. What should the nurse recognize about this finding?

a. Observed in patients with kyphosis.
b. Indicative of pectus excavatum.
c. A normal finding in a healthy adult.
d. An expected finding in a patient with a barrel chest.

Answer 2

ANS: C

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 (barrel chest), as in emphysema.This is a normal finding and is not associated with kyphosis or indicative of pectus excavatum.

Question 3

When assessing a patient’s lungs, what should the nurse recall about the left lung?

a. Consists of two lobes.
b. Is divided by the horizontal fissure.
c. Primarily consists of an upper lobe on the posterior chest.
d. Is shorter than the right lung because of the underlying stomach.

Answer 3

ANS: A

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

Question 4

Which statement about the apices of the lungs is true?

a. Are at the level of the second rib anteriorly.
b. Extend 3 to 4 cm above the inner third of the clavicles.
c. Are located at the sixth rib anteriorly and the eighth rib laterally.
d. Rest on the diaphragm at the fifth intercostal space in the midclavicular line (MCL).

Answer 4

ANS: B

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.

Question 5

Where does the trachea bifurcate on the anterior chest?

a. Costal angle
b. Sternal angle
c. Xiphoid process
d. Suprasternal notch

Answer 5

ANS: B

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

Question 6

During an assessment, the nurse knows that expected assessment findings in the normal adult lung include which findings?

a. Adventitious sounds and limited chest expansion
b. Muffled voice sounds and symmetric tactile fremitus
c. Increased tactile fremitus and dull percussion tones
d. Absent voice sounds and hyperresonant percussion tones

Answer 6

ANS: B

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.

Question 7

What are the primary muscles of respiration?

a. Diaphragm and intercostals
b. Sternomastoids and scaleni
c. Trapezii and rectus abdominis
d. External obliques and pectoralis major

Answer 7

ANS: A

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—sternomastoid, scaleni, and trapezii muscles. Forced expiration involves the abdominal muscles.

Question 8

A 65-year-old patient with a history of heart failure comes to the clinic stating “I keep waking up from sleep with shortness of breath.” Which action by the nurse is most appropriate?

a. Obtain a detailed health history of the patient’s allergies and a history of asthma.
b. Tell the patient to sleep on his or her right side to facilitate ease of respirations.
c. Assess for other signs and symptoms of paroxysmal nocturnal dyspnea.
d. Assure the patient that paroxysmal nocturnal dyspnea is normal and will probably
resolve within the next week.

Answer 8

ANS: C

Being awakened from sleep with shortness of breath is a symptom of paroxysmal nocturnal dyspnea. The nurse should assess for other signs and symptoms of paroxysmal nocturnal dyspnea. Paroxysmal nocturnal dyspnea is usually relieved by sitting upright.

Question 9

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

a. Between the scapulae
b. Third intercostal space, MCL
c. Over the lower lobes, posterior side
d. Fifth intercostal space, midaxillary line (MAL)

Answer 9

ANS: A

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

Question 10

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?

a. “Is caused by moisture in the alveoli.”
b. “Is caused by sounds generated from the larynx.”
c. “Reflects the blood flow through the pulmonary arteries.”
d. “Indicates that air is present in the subcutaneous tissues.”

Answer 10

ANS: B

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.

Question 11

During percussion, the nurse hears a dull percussion note elicited over a lung lobe. What is the most likely cause of this finding?

a. Shallow breathing
b. Normal lung tissue
c. Decreased adipose tissue
d. Increased density of lung tissue

Answer 11

ANS: D

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

Question 12

The nurse is observing the auscultation technique of a student nurse. What is the correct method to use when progressing from one auscultatory site on the thorax to another?

a. Side-to-side comparison
b. Top-to-bottom comparison
c. Posterior-to-anterior comparison
d. Interspace-by-interspace comparison

Answer 12

ANS: A

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 not correct.

Question 13

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

a. Normal sounds auscultated over the trachea.
b. Bronchial breath sounds that are normal in that location.
c. Vesicular breath sounds that are normal in that location.
d. Bronchovesicular breath sounds that are normal in that location.

Answer 13

ANS: C

Vesicular breath sounds are low-pitched, soft sounds with inspiration being longer than expiration. These breath sounds are expected over the peripheral lung fields where airflows through smaller bronchioles and alveoli

Question 14

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

a. Instructing the patient to take deep, rapid breaths
b. Instructing the patient to breathe in and out through his or her nose
c. Firmly holding the diaphragm of the stethoscope against the skin of the chest
d. Lightly holding the bell of the stethoscope against the skin on the chest to avoid friction

Answer 14

ANS: C

Firmly holding the diaphragm of the stethoscope against 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 patient should be instructed to take breaths a little deeper than usual but not to hyperventilate and to breathe through his or her mouth, not nose. The diaphragm not the bell should be used to auscultate breath sounds and holding the diaphragm of the stethoscope firmly against the chest is the correct way to auscultate breath sounds.

Question 15

The nurse is percussing over the lungs of a patient with pneumonia. If the patient has atelectasis, what sound will the nurse hear?

a. Tympany
b. Dullness
c. Resonance
d. Hyperresonance

Answer 15

ANS: B

A dull percussion note signals an abnormal density in the lungs, as with pneumonia, pleural effusion, atelectasis, or a tumor. Tympany is a hollow drum-like sound normally found with percussion over the intestines in the abdomen. Resonance is a low-pitched, clear, hollow sound that predominates in healthy lung tissue. Hyperresonance is a lower-pitched, booming sound found when too much air is present such as in emphysema or pneumothorax. An abnormal density in the lungs, such as atelectasis, pneumonia, pleural effusion, or a tumor would produce a dull note when percussed.

Question 16

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

a. When adventitious sounds are present
b. When the bronchial tree is obstructed
c. In conjunction with whispered pectoriloquy
d. In conditions of consolidation, such as pneumonia

Answer 16

ANS: B

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. Although there may be decreased breath sounds when adventitious sounds are heard or with consolidation, it is not expected. Decreased breath sounds are also not expected with whispered pectoriloquy.

Question 17

Which is a normal finding when assessing the respiratory system of an older adult?

a. Increased thoracic expansion
b. Decreased mobility of the thorax
c. Decreased anteroposterior diameter
d. Bronchovesicular breath sounds throughout the lungs

Answer 17

ANS: B

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 costal cartilages become calcified with aging, resulting in a less mobile thorax and thus also a slight decrease, not increase, in thoracic expansion. The chest cage commonly shows an increased, not a decreased, anteroposterior diameter and bronchovesicular breath sounds are not found throughout the lungs.

Question 18

A mother brings her 3-month-old infant to the clinic for evaluation of a cold. She tells the nurse that he has 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. What should the nurse do next?

a. Ask the mother if the infant has had trouble with feedings.
b. Assure the mother that these signs are normal symptoms of a cold.
c. Recognize that these are serious signs, and contact the physician.
d. Perform a complete cardiac assessment because these signs are probably indicative of early heart failure.

Answer 18

ANS: C

The infant is an obligatory nose breather until the age of 3 months. Normally no flaring of the nostrils and no sternal or intercostal retraction occurs. Significant 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 an assessment of the infant’s feeding is not a priority at this time. These signs are not normal, do not indicate heart failure, and an assessment of the infant’s feeding is not a priority at this time.

Question 19

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

a. Crepitus palpated at the costochondral junctions
b. Presence of bronchovesicular breath sounds in the peripheral lung fields
c. No diaphragmatic excursion as a result of a child’s decreased inspiratory volume
d. Irregular respiratory pattern and a respiratory rate of 40 breaths per minute at rest

Answer 19

ANS: B

Bronchovesicular breath sounds in the peripheral lung fields of the infant and young child up to age 5 or 6 years are normal findings. Their thin chest walls with underdeveloped musculature do not dampen the sound, as do the thicker chest walls of adults; therefore, breath sounds are loud and harsh. Crepitus is not a normal or expected finding in a child or any age patient. Although the technique of measuring diaphragmatic excursion using percussion is no longer recommended, you would still expect to see diaphragmatic excursion (movement of the diaphragm) in a 4-year-old child. The normal respiratory rate for a 4-year-old child is 20 to 24, so a respiratory rate of 40 while at rest would be tachypnea.

Question 20

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

a. Diaphragmatic excursion
b. Symmetric chest expansion
c. Presence of breath sounds
d. Shape and configuration of the chest wall

Answer 20

ANS: D

Inspection of the anterior chest includes shape and configuration of the chest wall; assessment of the patient’s level of consciousness and the patient’s 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. Diaphragmatic excursion is assessed by percussion of the posterior chest, not observation of the anterior chest; symmetric chest expansion is assessed by palpation, not by observation; and breath sounds are assessed by auscultation. Inspection of the anterior chest includes shape and configuration of the chest wall; assessment of the patient’s level of consciousness and the patient’s skin color and condition; quality of respirations; presence or absence of retraction and bulging of the intercostal spaces; and use of accessory muscles.

Question 21

The nurse would most likely hear fine crackles in which patient or situation?

a. A pregnant woman
b. A healthy 5-year-old child
c. The immediate newborn period
d. A patient with a pneumothorax

Answer 21

ANS: C

Fine crackles are commonly heard in the immediate newborn period as a result of the opening of the airways and a clearing of fluid. Persistent fine crackles would be noticed with pneumonia, bronchiolitis, or atelectasis. Fine crackles would not be expected in the
other options.

Question 22

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

a. In an obese patient
b. When part of the lung is obstructed or collapsed
c. When bulging of the intercostal spaces is present
d. When accessory muscles are used to augment respiratory effort

Answer 22

ANS: B

Unequal chest expansion occurs when part of the lung is obstructed or collapsed, as with pneumonia, or when guarding to avoid postoperative incisional pain. Chest expansion is still expected to be equal in obese patients, when there is bulging of intercostal spaces, and when accessory muscles are used in breathing.

Question 23

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?

a. Asthma
b. Emphysema
c. Airway obstruction
d. Pulmonary consolidation

Answer 23

ANS: D

Pathologic conditions that increase lung density, such as pulmonary consolidation, will enhance the transmission of voice sounds, such as bronchophony. Asthma, emphysema, and airway obstruction do not increase lung density and thus, do not enhance the
transmission of voices sounds.

Question 24

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

a. Musical in quality
b. Expected near the major airways
c. Usually caused by a pathologic disease
d. Similar to bronchial sounds except shorter in duration

Answer 24

ANS: B

Bronchovesicular breath sounds are moderate in pitch and amplitude and are equal in length in inspiration and expiration. They are heard over major bronchi where fewer alveoli are located posteriorly—between the scapulae, especially on the right; and anteriorly, around the upper sternum in the first and second intercostal spaces. The other responses are not correct.

Question 25

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?

a. Wheezes
b. Bronchophony
c. Bronchial sounds
d. Whispered pectoriloquy

Answer 25

ANS: A

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. Bronchophony and whispered pectoriloquy occur with pathologic conditions that increase lung density, such as pulmonary consolidation, which enhances the transmission of voice sounds. Asthma does not increase lung density. Instead, a patient with asthma has narrowed airways which results in wheezing

Question 26

A patient has a long history of chronic obstructive pulmonary disease (COPD). During the assessment, the nurse will most likely observe which of these?

a. Unequal chest expansion
b. Increased tactile fremitus
c. Atrophied neck and trapezius muscles
d. Anteroposterior-to-transverse diameter ratio of 1:1

Answer 26

ANS: D

An anteroposterior-to-transverse diameter ratio of 1:1 or barrel chest is observed in individuals with COPD 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. 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 evident. 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.)

Question 27

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. What do these findings suggest?

a. Bronchitis
b. Pneumothorax
c. Acute pneumonia
d. Asthmatic attack

Answer 27

ANS: B

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 evident. 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.)

Question 28

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, the use of accessory neck muscles, prolonged expiration, intercostal retractions, decreased breath sounds, and expiratory wheezes. What do these findings suggest?

a. Asthma
b. Atelectasis
c. Lobar pneumonia
d. Heart failure

Answer 28

ANS: A

Asthma is allergic hypersensitivity to certain inhaled particles that produces inflammation and a reaction of bronchospasm, which increases airway resistance, especially during expiration. An increased respiratory rate, the use of accessory muscles, a retraction of the intercostal muscles, prolonged expiration, decreased breath sounds, and expiratory wheezing are all characteristics of asthma. Atelectasis presents with decreased or absent breath sounds but no prolonged expiration or expiratory wheezing. Lobar pneumonia presents with tachycardia and loud bronchial breathing with patent bronchus but no prolonged expiration or expiratory wheezing. Heart failure can present with both crackles and wheezing but does not have a prolonged expiration, and based on this patient’s history of allergies and the symptoms occurred when he was working in the yard, asthma is the most likely problem.

Question 29

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

a. Decrease in small airway closure occurs, leading to problems with atelectasis.
b. Severe dyspnea is experienced on exertion, resulting from changes in the lungs.
c. Respiratory muscle strength increases to compensate for a decreased vital capacity.
d. Lungs are less elastic and distensible, which decreases their ability to collapse and recoil.

Answer 29

ANS: D

In the aging adult, the lungs are less elastic and distensible, which decreases their ability to collapse and recoil. Vital capacity is decreased, and a loss of intra-alveolar septa occurs, 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.

Question 30

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 best reply by the nurse?

a. “The diaphragm becomes fixed during pregnancy, making it difficult to take in a deep breath.”
b. “The increase in estrogen levels during pregnancy often causes a decrease in the diameter of the rib cage and makes it difficult to breathe.”
c. “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.”
d. “This increased awareness of the need to breathe is normal as the fetus grows because of the increased oxygen demand on the mother’s body, which results in an increased respiratory rate.”

Answer 30

ANS: C

During pregnancy, the woman may develop an increased awareness of the need to breathe. Some women may interpret this as dyspnea, although structurally nothing is wrong. Increases in estrogen relax the chest cage ligaments, causing an increase in the transverse diameter. Although the growing fetus increases the oxygen demand on the mother’s body, this increased demand is easily met by the increasing tidal volume (deeper breathing). Little change occurs in the respiratory rate.

Question 31

A 35-year-old recent immigrant is being seen in the clinic for symptoms of a cough associated with rust-colored sputum, low-grade afternoon fevers, and night sweats for the past 2 months. Based on these findings, what is the most likely cause?

a. Pneumonia
b. Bronchitis
c. Tuberculosis
d. Pulmonary edema

Answer 31

ANS: C

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. Pneumonia typically presents with yellow-green sputum and pink, frothy sputum is characteristic of pulmonary edema. Bronchitis alone usually has a dry, not productive, cough.

Question 32

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 patient?

a. Fever, dry nonproductive cough, and diminished breath sounds
b. Rasping cough, thick mucoid sputum, wheezing, and bronchitis
c. Productive cough, dyspnea, weight loss, anorexia, and tuberculosis
d. Shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, and ankle edema

Answer 32

ANS: D

A person with heart failure often exhibits 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 indicate tuberculosis; fever, dry nonproductive cough, and diminished breath sounds may indicate Pneumocystis jiroveci (P. carinii) pneumonia.

Question 33

A patient comes to the clinic reporting a cough that is worse at night but not as bad during the day. What does the nurse suspect?

a. Pneumonia
b. Postnasal drip or sinusitis
c. Exposure to irritants at work
d. Chronic bronchial irritation from smoking

Answer 33

ANS: B

A cough that primarily occurs 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.

Question 34

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

a. Croup
b. Tuberculosis
c. Viral infection
d. Pulmonary edema

Answer 34

ANS: D

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.

Question 35

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

a. Listening to at least one full respiration in each location
b. Listening as the patient inhales and then going to the next site during exhalation
c. If the patient is modest, listening to sounds over his or her clothing or hospital gown
d. Instructing the patient to breathe in and out rapidly while listening to the breath
sounds

Answer 35

ANS: A

During auscultation of breath sounds with a stethoscope, listening to one full respiration in each location is important. During the examination, the nurse should monitor the breathing and offer times for the person to breathe normally to prevent possible dizziness. The nurse should listen with the diaphragm of the stethoscope directly on the skin, not over a patient’s gown or clothing.

Question 36

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?

a. Absent or decreased breath sounds
b. Productive cough with thin, frothy sputum
c. Chest pain that is worse on deep inspiration and dyspnea
d. Diffuse infiltrates with areas of dullness upon percussion

Answer 36

ANS: C

Findings for pulmonary embolism include chest pain that is worse on deep inspiration, dyspnea, apprehension, anxiety, restlessness, partial arterial pressure of oxygen (PaO2) less than 80 mm Hg, diaphoresis, hypotension, crackles, and wheezes. Thin, frothy sputum is characteristic of pulmonary edema and diffuse infiltrates with areas of dullness upon percussion are characteristic
of pneumonia or some type of lung consolidation.

Question 37

During palpation of the anterior chest wall, the nurse notices a coarse, crackling sensation over the skin surface. What does this finding indicate?

a. Crepitus
b. Friction rub
c. Tactile fremitus
d. Adventitious sounds

Answer 37

ANS: A

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, such as after open thoracic injury or surgery. A pleural friction rub is produced when inflammation of the parietal or visceral pleura causes a decrease in the normal lubricating fluid. The opposing surfaces make a coarse grating sound when rubbed together during breathing and is best detected by auscultation, not palpation. Tactile fremitus occurs with conditions that increase the density of lung tissue, thereby making a better conducting medium for palpable vibrations, not a coarse crackling sensation. Adventitious sounds are abnormal lung sounds heard by auscultation, not palpated.

Question 38

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. What does this finding indicate?

a. Fine wheezes
b. Vesicular breath sounds
c. Fine crackles and may be a sign of pneumonia
d. Atelectatic crackles that do not have a pathologic cause

Answer 38

ANS: D

One type of adventitious sound, atelectatic crackles, does not have a pathologic cause. They are short, popping, crackling sounds that sound similar to 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 older adults), 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. Although crackles can be a sign of pneumonia, this patient’s crackles resolved after a few deep breaths which would not happen if there was pneumonia.

Question 39

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

a. Bradypnea
b. Hypoventilation
c. Cheyne-Stokes respirations
d. Chronic obstructive breathing

Answer 39

ANS: B

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. Cheyne-Stokes respirations are a cycle in which
respirations gradually wax and wane in a regular pattern, increasing in rate and depth and then decreasing. Chronic obstructive breathing is characterized by normal inspiration and prolonged expiration to overcome increased airway resistance. This patient’s breathing is hypoventilation.

Question 40

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

a. Stridor
b. Crackles
c. Wheezing
d. Friction rub

Answer 40

ANS: D

A patient with pleuritis will exhibit a pleural friction rub upon auscultation. This sound is made when the 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 pneumonia, heart failure, chronic bronchitis, and other diseases. Wheezes are associated with diffuse airway obstruction caused by acute asthma or chronic emphysema.

Question 41

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

a. As the patient says a long “ee-ee-ee” sound, the examiner hears a long “aaaaaa” sound.
b. As the patient says a long “ee-ee-ee” sound, the examiner also hears a long “ee-ee-ee” sound.
c. As the patient repeatedly says “ninety-nine,” the examiner clearly hears the words “ninety-nine.”
d. Voice sounds are faint, muffled, and almost inaudible when the patient whispers “one, two, three” in a very soft voice.
e. When the patient speaks in a normal voice, the examiner can hear a sound but cannot exactly distinguish what is being said.

Answer 41

ANS: B, D, E

As a patient repeatedly says “ninety-nine,” normally the examiner hears voice sounds but cannot distinguish what is being said. If a clear “ninety-nine” is auscultated, then it could indicate increased lung density, which enhances the transmission of voice sounds, which 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, which is a measure of egophony. If the examiner hears a long “aaaaaa” sound instead, this sound 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 examiner clearly hears the whispered voice, as if the patient is speaking through the stethoscope, then consolidation of the lung fields may exist.