Exam 3 chapter 11

Question 1

What requires adequate oxygenation for optimal functioning?

Answer 1

Metabolism, motion, tissue integrity, sleep, and nutrition

Question 2

Ventilation

Answer 2

Process of moving gases in and out of the lungs by inspiration and expiration

Question 3

Diffusion

Answer 3

The process by which oxygen and carbon dioxide move from areas of high concentration to areas of lower concentration

Question 4

There are three main structures within the thorax (chest)

Answer 4

The mediastinum and the right and left pleural cavities

Question 5

The mediastinum is positioned in the?

Answer 5

Middle of the chest. Within it lie the heart, the arch or aorta, the superior vena cava, the lower esophagus, and the traches

Question 6

The pleural cavities contain?

Answer 6

The lungs. They are lined with two types of serous membranes: the parietal and visceral pleura.

• The chest wall and diaphragm are protected by the parietal pleura, and the lungs are protected by the visceral pleura
• a small amount of fluid lubricates the space between the pleurae to reduce friction as the lungs move during inspiration and expiration

Question 7

The right lung has? The left lung has?

Answer 7

Right: Three lobes
Left: Two lobes
-Each lung extends anteriorly about 1.5 inches (4cm) above the first rib into the base of the neck in adults and posteriorly approximately to the level of T1 (first thoracic vertebra)
-the base or lower border of each lung expands approximately down to T12 during deep inspiration and rises approximately to T9 on expiration

Question 8

Most of the respiratory system is protected by the?

Answer 8

Thoracic cage consisting of 11 thoracic vertebrae, 12 pairs of ribs, and the sternum

• all ribs connected to the thoracic vertebrae posteriorly
• the first 7 ribs are also connected anteriorly to the sternum by the costal cartilages
• the costal cartilages of the eight to tenth ribs are connected immediately superior to the ribs

Question 9

The eleventh and twelfth ribs are?

Answer 9

Unattached anteriorly and are called floating ribs

-tips of the eleventh ribs are located in the posterior thorax

Question 10

The adult sternum is about 7 inches (17cm) long and has three components:

Answer 10

The manubrium, the body, and the xiphoid process

• manubrium and the body of the sternum articulate with the first seven ribs; the manubrium also supports the clavicle
• the intercostal space (ICS) is the area between the ribs
• ICS is named according to the rib immediately above it

Question 11

Primary muscles of breathing

Answer 11

The diaphragm and the intercostal muscles

• during inspiration the diaphragm contracts and pushes the abdominal contents down while the intercostal muscles help to push the chest wall outward
• these combined efforts decrease the intrathoracic pressure, which creates a negative pressure within the lungs compared with the pressure outside the lungs
• this pressure difference causes the lungs to fill with air
• during expiration the muscles relax, expelling the air as the intrathroacic pressure rises
• accessory muscles that may contribute to respiratory effort include anteriorly the sternocleidomastoid, scalenus, pectoralis minor, serratus anterior, and rectus abdominis muscles and posteriorly the serratus posterior superior, transverse thoracic, and serratus posterior inferior muscles

Question 12

During inspiration air is drawn in through the mouth or nose and passes through the pharynx and larynx to reach the?

Answer 12

trachea, a flexible tube approximately 4 inches (10cm) long in the adult

Question 13

Structures that make up the upper respiratory airway

Answer 13

Nose, pharynx, larynx, and trachea
-has three functions in respiration: to conduct air to the lower airway, to protect the lower airway from foreign matter, and to warm, filter, and humidify inspired air

Question 14

The lower airway consists of the?

Answer 14

Left and right main stem bronchi, the segmental and subsegmental bronchi, the terminal bronchioles, and alveoli

Question 15

The trachea splits into a?

Answer 15

Left and right main-stem bronchus at about the level of T4 and T5

• right bronchus is shorter, wider, and more vertical than the left
• bronchi are further subdivided into increasingly smaller bronchioles
• each bronchiole opens into an alveolar duct and terminates in multiple alveoli, where gas exchanges occur

Question 16

Present health status: Do you have chronic illnesses?

Answer 16

Many chronic illnesses can cause symptoms that affect the respiratory system, including heart disease or renal disease, which may cause pulmonary edema

Question 17

An increased frequency of allergies may indicate?

Answer 17

The onset of new allergies or ineffective therapy for respiratory disease

Question 18

Individuals who have no difficulty breathing until they are active may have?

Answer 18

Pulmonary or heart disease that limits the availability of oxygen needed during exertion

Question 19

Risk factors for lung cancer

(M)=modifiable risk

Answer 19

• Tobacco smoking: #1 risk factor for lung cancer (M)
• Secondhand smoke (M)
• Radon: naturally occurring gas comes from rocks/dirt and can get trapped in houses/building. Causes 20,000 cases of lung cancer each year. 2nd leading cause
• Asbestos (M)
• Environmental exposure in some workplaces (M)
• Air pollution (M)
• Radiation therapy to chest: i.e. cancer survivors
• Personal and family history

Question 20

Home environment factors that may affect breathing

Answer 20

• Air pollution
• Possible allergens in home such as pets
• Type of heating or air conditioning, including filtering system, humidification, and ventilation
• Hobbies: Woodworking, plants, metal work
• Exposure to the smoke of others in your home

Question 21

Recording tobacco use

Answer 21

Cigarette use is documented by pack-years

-pack-year is the number of years pt smoked multiplied by the number of packs of cigarettes smoke each day

Question 22

A cough can be acute (sudden onset and usually lasting less than 3 weeks) or chronic (longer than 3 weeks).
Common causes of acute cough are?
Chronic?

Answer 22

Acute: viral infections, allergic rhinitis, acute asthma, acute bacterial sinusitis, or environmental irritants
Chronic: postnasal drip, gastroesophageal reflux disease (GERD), asthma, infections such as chronic bronchitis, blood pressure drugs (Angiotensin-converting enzyme (ACE) inhibitors such as captopril, commonly prescribed for high BP and heart failure, and known to cause chronic cough)

Question 23

A description of a cough may provide clues to the cause.

Answer 23

• Viral pneumonia causes a dry cough

- Bacterial pneumonia causes a productive cough

Question 24

The frequency of sputum production and the time of day most sputum is produced should be explored.

Answer 24

• Increased sputum in the morning implies an accumulation of sputum during the night and is common with bronchitis
• Sputum production with a change in position suggests lung abscess and bronchiectasis
• Amount of sputum production can vary from a few tsps to a copious amount (a pint or more)

Question 25

Documenting the appearance of the sputum is important. Some conditions have characteristic sputum production

Answer 25

• white or clear sputum may occur with colds, viral infections, or bronchitis
• yellow or green sputum may occur with bacterial infections
• black sputum may occur with smoke or coal dust inhalation
• rust colored sputum may occur with TB or pneumococcal pneumonia
• hemoptysis: the expectoration of sputum containing blood. Can vary

Question 26

The consistency of sputum may be described as?

Answer 26

Thin, thick, gelatinous, sticky, frothy

• pink, frothy sputum with dyspnea is associated with pulmonary edema
• Thick sputum is commonly associated with cystic fibrosis

Question 27

Foul smelling (fetid) sputum is typically associated with

Answer 27

bacterial pneumonia, lung abscess, or bronchiectasis

Question 28

A cough may be a symptom of pulmonary problems or it may exist in conjunction with other problems. Related signs and symptoms are important factors to assess when determining the underlying cause of the cough. For example;

1) a cough associated with a fever, SOB, and noisy breath sounds may indicate a?
2) Tightness of the chest associated with SOB and nonproductive cough is associated with?

Answer 28

1) Lung infection

2) Asthma

Question 29

Orthopnea

Answer 29

Difficulty breathing when the individual is lying down

Question 30

Paroxysmal nocturnal dyspnea

Answer 30

SOB that awakens the individual in the middle of the night, usually in a panic with the feeling of suffocation

Question 31

Describing dyspnea

Answer 31

Count the words the the patient can say between breaths

Question 32

Chest pain caused by respiratory disease is usually associated with disorders affecting the chest wall or parietal pleura (e.g. pneumonia). In contrast, chest pain associated with heart disease (primarily in men) is usually associated with?

Answer 32

Radiating pain to the jaw, left arm, and back and women report SOB, diaphoresis, nausea, epigastric pain, and fatigue

Question 33

A sharp, abrupt pain associated with deep breathing may be an indication of?

Answer 33

Pleural lining irritation, also called pleuretic chest pain
-men reporting chest pain due to heart disease such as MI often describe viselike and tight chest pain, while women report other symptoms such as SOB

Question 34

atelectasis

Answer 34

Collapse of alveoli

Question 35

Indications of respiratory distress include an?

Answer 35

Appearance of apprehension, restlessness, nasal flaring, supraclavicular or intercostal retractions, use of accessory muscles

• pursed lip breathing: exhalation through the mouth with lips pursed together to slow exhalation seen in pt’s with COPD or asthma
• Tripod position suggests respiratory distress in pt’s w/COPD or asthma. Enhances accessory muscle use
• Paradoxical chest wall movement may occur after chest trauma when chest wall moves during inspiration and out during expiration

Question 36

Respirations normal: An expected variation is the abdominal breathing pattern. Men tend to use?

Answer 36

Abdominal breathing (or diaphragmatic breathing), whereas women tend to use more thoracic breathing
-a sigh is another expected variation observed with breathing. It is an occasional interspersed deep breath associated with an expected pattern

Question 37

Respiration Abnormal findings

Answer 37

Bradypnea, tachypnea, hyperventilation, Kussmaul air trapping, and Cheynes-Stokes

• Chest retraction appears when intercostal muscles are drawn inward between the ribs and indicates airway obstruction that may occur during an asthma attack or pneumonia
• frequent sighing is considered an abnormal finding and may indicate fatigue or anxiety

Question 38

Nail beds should be

Answer 38

pink, with an angle of 160 degrees at the nail bed

• skin and lip tones vary; therefore general color should be consistent with ethnicity
• in dark skinned patients cyanosis is assessed by inspecting the oral mucosa and lips

Question 39

Abnormal findings for nails, skin, ips

Answer 39

Cyanosis or pallor of the nails, skin, or lips may be a sign of inadequate oxygenation of tissues caused by an underlying respiratory or cardiovascular condition

• yellow discoloration of fingers maybe associated with cigarette smoking
• clubbing of nails is associated with chronic hypoxia observed in patients with cystic fibrosis or COPD

Question 40

Expected findings: Inspect the posterior thorax for shape, symmetry, and muscle development.

Answer 40

The ribs should slope down at about 45 degrees relative to the spine. The thorax should be symmetric. The spinous processes should appear in a straight line. The scapulae should be bilaterally symmetric. Muscle development should be equal

Question 41

Patients with emphysema may have a?

Answer 41

Barrel shaped chest due to chronic air trapping in the alveoli

Question 42

Expected findings for auscultating the posterior and lateral thoraxes for breath sounds

Answer 42

Breath sounds should be clear over the posterior and lateral thoraxes. Vesicular and bronchovesicular breath sounds are expected

Question 43

Abnormal findings for breath sounds

Answer 43

Abnormal breath sounds heard over areas of the lungs where they are not expected

• Bronchial breath sounds are abnormal if heard anywhere over the posterior or lateral thorax and may indicate consolidation of the lung, which may be found with pneumonia. (The sound heard is loud and high pitched. It sounds as if the air source is just under the stethoscope)
• bronchovesicular breath sounds should be considered abnormal when heard over the peripheral lung areas

Question 44

Bronchial
Pitch
Intensity
Duration: Inspiration and expiration
Expected location
Abnormal location

Answer 44

Pitch: High
Intensity: Loud
Duration: Inspiration and expiration: Insp < Exp 1:2
Expected location: Over trachea
Abnormal location: Over peripheral lung fields

Question 45

Bronchovesicular
Pitch
Intensity
Duration: Inspiration and expiration
Expected location
Abnormal location

Answer 45

Pitch: Moderate
Intensity: Medium
Duration: Inspiration and expiration: Insp=Exp 1:1
Expected location: 1st & 2nd intercostal spaces at sternal border anteriorly: posteriorly at T4 medial to scapula
Abnormal location: over peripheral lung fields

Question 46

Vesicular
Pitch
Intensity
Duration: Inspiration and expiration
Expected location
Abnormal location

Answer 46

Pitch: Low
Intensity: Soft
Duration: Inspiration and expiration: Insp > Exp 2.5:1
Expected location: Peripheral lung fields
Abnormal location: not applicable

Question 47

Vesicular breath sounds should be heard over?

Answer 47

Almost all of the posterior & lateral thoraxes.

Question 48

Bronchovesicular breath sounds should be heard over the?

Answer 48

Upper center area of the posterior thorax between the vertebrae between the scapulae

Question 49

The term stridor is more prominent over the neck than the chest and is used to describe a?

Answer 49

Harsh, high-pitched sound associated with breathing that is often caused by laryngeal or tracheal obstruction

Question 50

Crackles (previously called rales)

Answer 50

Fine, high-pitched crackling and popping noises (discontinuous sounds) heard during inspiration and sometimes expiration; not cleared by cough or altered by changes in body position
-may be heard in pneumonia, heart failure, restrictive pulmonary diseases

Question 51

Wheeze (also called sibilant wheeze)

Answer 51

High-pitched, musical sound similar to a squeak; heard more commonly during expiration but may be heard during inspiration; occurs in small airways
-heard in airway diseases when the thickness of airways increases such as asthma

Question 52

Rhonchi (also called sonorous wheeze)

Answer 52

Low-pitched, course, loud , low snoring or moaning tone; heard primarily during expiration may also be heard during inspiration; coughing may clear
-heard in disorders causing obstruction of the trachea or bronchus such as bronchitis or COPD

Question 53

Pleural friction rub

Answer 53

Superficial, low-pitched, coarse rubbing or grating sound; sounds like two surfaces rubbing together; heard throughout inspiration and expiration; loudest over the lower anterolateral surface; not cleared by cough
-heard in individuals with pleurisy (inflammation of the pleural surfaces) or with pericarditis

Question 54

Abnormal findings for anterior thorax

Answer 54

The barrel chest caused by emphysema increases the costal angle
-other chest wall skeletal deformities include scoliosis, pectus carinatum (pigeon chest), and pectus excavatum (funnel chest)

Question 55

The anteroposterior (AP) diameter of the chest should be approximately

Answer 55

One half the lateral diameter or about a 1:2 ratio of AP to lateral diameter. Thus the distance from the front to the back of the chest should be half the distance from one side of the chest to the other

Question 56

Abnormal findings for the anterior thorax (anteroposterior (AP)

Answer 56

In disorders that cause lung hyperinflation such as emphysema, the chest wall may have a barrel chest appearance because of an increased AP diameter. The ribs are more horizontal and the chest looks as if it is held in constant inspiration

Question 57

Vesicular breath sounds should be heard throughout the?

Answer 57

Anterior thorax, including the apex of the lungs above the clavicles

Question 58

Bronchovesicular breath sounds are expected sounds heard over the?

Answer 58

Central area of the anterior thorax around the sternal border. These sounds are heard in an area that approximates the area where the bronchi split off from the trachea

Question 59

Bronchial breath sounds are the expected sounds heard over the?

Answer 59

Trachea and the area immediately above the manubrium

Question 60

Abnormal findings: when a pleural friction rub is heard, you can distinguish the source (lung or heart) by asking the patient to?

Answer 60

hold their breath. If rub is not heard, the source is lung pleura rubbing together. If sound persists, it is caused by pericardial pleura rubbing together

Question 61

Expected findings: the posterior thoracic muscles

Answer 61

vertebrae should be straight and painless from C7 through T12. The scapulae should by symmetric, and the surrounding musculature well developed. The posterior ribs should be stable and painless. The posterior rib cage should be symmetric and firm

Question 62

Expected findings: anterior thoracic muscles

Answer 62

The clavicles should be symmetric, and the surrounding musculature well developed. The anterior ribs should be stable and painless. The rib cage should be symmetric and firm. The sternum and xiphoid should be relatively inflexible

Question 63

Abnormal findings for posterior and anterior thoracic muscles

Answer 63

Note any crepitus, which feels like a crackly sensation under your fingers. This finding indicates air in the subcutaneous tissue caused by an air leak from somewhere in the respiratory tree.

• Pleural friction rub may be felt as a coarse, grating sensation during inspiration. It occurs secondary to inflammation of the pleural surface.
• muscular development that is asymmetric or an unstable chest wall may indicate a thoracic disorder such as fractured ribs

Question 64

Palpate the posterior and anterior thoracic walls for vocal (tactile) fremitus. Perform when?

Answer 64

Congestion, obstruction, or compression of lung tissue is suspected

Question 65

Fremitus provides information about the density of underlying lung tissue and thorax. Vocal fremitus is a ?

Answer 65

Vibration resulting from verbalizations. You can feel this vibration using the palmar surface of your hand and fingers or the ulnar surfaces of your hands

Question 66

The fremitus should feel?

Answer 66

Bilaterally equal over posterior and anterior chest walls, although the quality of the vibrations may vary from person to person because of chest wall density and relative location of the bronchi to the chest wall

Question 67

Abnormal findings for fremitus

Answer 67

Vibrations feel unequal when comparing sides. Decreased or absent fremitus is felt unilaterally when the vibrations are blocked, which may occur in pt’s w/pneumothorax, pleural effusion, atelectasis, or bronchial obstruction

• decreased fremitus is felt bilaterally in pt’s w/COPD, massive pulmonary edema, or excess fat tissue on the chest
• increased femitus is detected when the vibrations feel enhanced. This occurs when lung tissues are congested or consolidated, which may occur in pt’s who have pneumonia or a tumor

Question 68

Abnormal findings for trachea

Answer 68

One cause of tracheal shift is an increase in lung volume of the contralateral lung and/or pleural space caused by pneumothorax, large pleural effusion, or massive consolidation.
-another cause is decrease in volume of the ipsilateral lung caused by atelectasis

Question 69

Advanced practice techniques

Answer 69

• percuss thorax for tone
• percuss the thorax for diaphragmatic excursion
• auscultate the thorax for vocal sounds (vocal resonance)

Question 70

How to document expected findings

Answer 70

Breathing quiet and effortless at a rate of 16 breaths/min

• skin, nails, and lips appropriate color for individual’s ethnic background
• thorax symmetric, w/ribs sloping downward at about 45 degrees relative to the spine
• Muscle development of the thorax equal bilaterally w/out tenderness
• thoracic expansion symmetric bilaterally
• Spinous processes in alignment; scapulae, bilaterally symmetric
• the anteroposterior (AP) diameter of chest approximately a 1:2 ratio to lateral diameter
• Trachea midline
• Breath sounds clear, w/vesicular breath sounds heard over most lung fields, bronchovesicular breath sounds in the posterior chest over the upper center area of the back and around the sternal border, and bronchial breath sounds heard over the trachea

Question 71

Assessing neonates and infants requires use of?

Answer 71

Different equipment and an unhurried approach.

• use a pediatric stethoscope when examining an infant or child
• infant must be undressed at least to the diaper to perform an adequate assessment
• keep infant covered when you are not performing the examination to prevent exposure and cooling
• conduct examination while infant is calm
• by age 2-3 child is usually cooperative during the respiratory exam. before that age you need to develop a relationship w/the child to improve cooperation during exam

Question 72

Assessing older adults

Answer 72

Use unhurried approach & may find expected variations from adults such as changes in the musculoskeletal system that affect respiratory function
-posterior thoracic stooping or bending or kyphosis may alter the thorax wall configuration and make thoracic expansion more difficult

Question 73

Acute bronhitis

Answer 73

Inflammation of the mucous membranes of the bronchial tree
-clinical findings: cough is initially nonproductive, but after a few days, may become productive with yellow or green mucus. Pt’s may complain of substernal chest pain that is aggravated by coughing. Fever and malaise. Rhonchi are heard on auscultation, w/wheezing heard over coughing

Question 74

Pneumonia

Answer 74

Inflammation of the terminal bronchioles and alveoli
-clinical findings: viral pneumonia tends to produce a nonproductive cough or clear sputum, whereas bacterial pneumonia causes productive cough that may produce white, yellow, or green sputum. Increased tactile femitus and crackles may be found during an examination. Changes in vital signs include fever, tachycardia, and tachypnea, shaking chills, malaise, and pleuritic chest pain

Question 75

Pleural effusion

Answer 75

an accumulation of serous fluid in the pleural space between the visceral and parietal pleurae
-clinical finding: manifestations depend on the amount of fluid accumulation and the position of the patient. Signs may be fever, tachypnea, dyspnea, tachycardia, decreased fremitus, trachea shifted to the other side, and absent breath sounds on the affected side. Symptoms may include sharp chest pain that is worse with cough or deep breaths

Question 76

Asthma

Answer 76

Hyperreactive airway disease characterized by bronchoconstriction, airway obstruction, and inflammation. The number of adults diagnosed with asthma in 2013 was 16,540
-clinical findings: tachycardia, tachypnea with prolonged expiration, audible wheeze, dyspnea, anxious appearance, possible use of accessory muscles, and cough. Expiratory and occastionally inspiratory wheeze and diminished breath sounds are common

Question 77

Emphysema

Answer 77

Destruction of the alveolar walls causes permanent abnormal enlargement of the air spaces in emphysema. The number of adults ever diagnosed w/emphysema in 2014 was 4.1 million
-clinical findings: classic appearance of a pt w/advanced emphysema is an underweight individual w/a barrel chest who becomes short of breath w/minimal exertion. When pt is SOB, pursed-lip breathing and tripod position are frequently observed. Other signs may be diminished breath sounds, possible wheezing or crackles, and increased anteroposterior to lateral diameter

Question 78

Chronic bronchitis

Answer 78

Characterized by hypersecretion of mucus by the goblet cells of the trachea and bronchi, resulting in a productive cough for 3 months in each of 2 successive years. Number of adults diagnosed with chronic bronchitis in 2014 was 8.7 million
-clinical findings: symptoms of chronic bronchitis are productive cough increased mucus production, cyanosis, and dyspnea. Rhonchi, sometimes cleared by coughing

Question 79

Pneumothorax

Answer 79

Air in pleural spaces results in a pneumothorax. 3 types: closed, which may be spontaneous, traumatic, or iatrogenic (caused by illness or medical treatment); open, which occurs following penetration of the chest by either injury or surgical procedure; tension, which develops when air leaks into the pleura and cannot escape

• clinical findings: signs vary, minor collapse slight SOB, anxious, & report chest pain. Large amount of lung collapses, the pt may experience severe respiratory distress, including tachycardia, dyspnea, tachypnea, and cyanosis. Breath sounds over affected area are absent. Decreased chest wall movement on affected side may be noted.
• pt may have paradoxical chest wall movement, when the chest wall moves in on inspiration and out on expiration. if severe, there may be tracheal displacement toward the unaffected side with a mediastinal shift (tension pneumothorax)

Question 80

Hemothorax

Answer 80

Blood in pleural space caused by chest injury results in hemothorax, but it also may be a complication of thoracic surgery
-clinical findings: chest pain, hypotension; cold clammy skin; tachycardia; rapid, shallow breathing; dyspnea

Question 81

Atelectasis

Answer 81

Collapsed alveoli caused by external pressure from a tumor, fluid, or air in the pleural space (compression atelectasis) or by lack of air from hypoventilation or obstruction by secretions (absorption atelectasis)
-clinical findings: affected area has decreased fremitus and diminished or absent breath sounds. The oxygen saturation may decrease to less than 90%

Question 82

Lung cancer

Answer 82

Malignancy that is an uncontrolled growth of anaplastic cells in one or both lungs. Lung cancer mainly occurs in older adults. Average age at time of diagnosis is about 70.
-clinical findings: persistent cough, pain in chest, shoulder, or back unrelated to pain of coughing, hemoptysis, and dyspnea. Lung sounds may sound as expected or be diminished over affected area. If there is a partial obstruction of airways from the tumor, wheezes may be heard. Generalized symptoms may be loss of appetite, unexplained weight loss, fatique

Question 83

A nurse suspects a viral infection or upper respiratory allergies when the patient describes the sputum as being which color?

Answer 83

clear

Question 84

During inspection of the respiratory system the nurse documents which finding as abnormal?

1) skin color consistent with patient’s ethnicity
2) 1:2 ratio of anteroposterior to lateral diameter
3) Respiratory rate is 20 breaths/min
4) Patient leaning forward with arms braced on the knees

Answer 84

4

Question 85

A patient has an infection of the terminal bronchioles and alveioli that involves the right lower lobe of the lung. Which abnormal findings are expected?

Answer 85

Prolonged expiration with an occasional wheeze in the right lower lobe

Question 86

On auscultation of a patient’s lungs, the nurse hears a low-pitched, coarse, loud, and low snoring sound. Which term does he nurse use to document this finding?

Answer 86

Rhonchi

Question 87

Which question gives the nurse further information about the patient’s complaint of chest pain?

Answer 87

“How would you describe the chest pain?”

Question 88

A nurse finds the patient’s anteroposterior diameter of the chest to be the same as the lateral diameter. Based on this finding, what additional data would the nurse anticipate?

Answer 88

Decreased breath sounds on auscultation

Question 89

How does the nurse palpate the chest for tenderness, bulges, and symmetry?

Answer 89

With the palmar surface of fingers of both hands, feels the consistency of the skin over the chest and the alignment of vertebrae

Question 90

Which breath sounds are expected over the posterior chest of an adult?

Answer 90

Vesicular

Question 91

Narrowing of the bronchi creates which advenitious sound?

Answer 91

Wheeze

Question 92

A nurse is auscultating the lungs of a healthy female patient and hears crackles on inspiration. What action can the nurse take to ensure this is an accurate finding?

Answer 92

Ask patient to cough then repeat the auscultation

Question 93

A patient complains to the nurse of coughing up green phlegm and is having difficulty breathing at rest. The nurse suspects:
  a viral infection.
  tuberculosis.
  pulmonary edema.
  bacterial pneumonia.

Answer 93

bacterial pneumonia.

The sputum by bacterial pneumonia also will have a foul smell. Viral infections usually are associated with the production of white or clear mucus. Sputum production with tuberculosis tends to be a rust color. Pink frothy sputum is a classic finding in patients with pulmonary edema.

Question 94

The nurse assesses a patient who has a costal angle greater than 90 degrees. What is the most likely cause of this finding?
  Chronic obstructive pulmonary disease
  Pneumothorax
  Infant respiratory distress syndrome
  Atelectasis

Answer 94

Chronic obstructive pulmonary disease

The costal angle increases because of an increased AP diameter. Pneumothorax is an acute condition that does not affect the shape of the chest. Infant respiratory distress syndrome is an acute condition that does not affect the shape of the chest. Atelectasis is an airless state of alveoli, but it will not affect the shape of the chest.

Question 95

The nurse auscultates prolonged expiration with expiratory wheezing and diminished breath sounds while assessing a patient. What does the nurse suspect?
  Tuberculosis
  Pneumonia Incorrect
  Croup
  Asthma

Answer 95

Asthma

Asthma impairs airway movement, which contributes to wheezes and decreased breath sounds. Tuberculosis typically is associated with a cough, fever, and night sweats. Pneumonia is associated with a productive cough and fever. Croup is associated with labored breathing, fever, and a bark-like cough.

Question 96

The nurse is palpating a patient’s chest wall. What can be accomplished with palpation of the chest?
  Approximation of lung size
  Determination of oxygenation
  Assessment of equal chest expansion
  Identification of lung sounds

Answer 96

Assessment of equal chest expansion

Thoracic expansion is assessed easily. Lung size is not approximated. Oxygenation is best determined by skin color, mental status, and lab tests. Lung sounds are assessed through auscultation.

Question 97

The nurse percusses a patient’s chest and feels dullness. The nurse suspects which diagnosis?
Emphysema
Pneumonia
Bronchiectasis
Chronic obstructive pulmonary disease (COPD)

Answer 97

Pneumonia

Dullness can be caused by consolidation. Hyperresonance usually is percussed with this disease process. Bronchiectasis is associated with a rounded chest wall and may be characterized by resonance or hyperresonance. COPD typically is characterized by hyperresonance.

Question 98

A nurse hears inspiratory and expiratory wheezes bilaterally. What is the meaning of this finding?
  Consolidation in alveoli
  Narrowed airways
  Sputum in the bronchi
  Fluid in the alveoli

Answer 98

Narrowed airways

Air moving within narrowed bronchi creates the wheezing sound. Consolidation would cause decreased or absent breath sounds. Sputum causes rhonchi. Fluid in the alveoli causes crackles.

Question 99

A nurse hears bronchovesicular sounds in the posterior chest on either side of the spine. This finding indicates:
  a normal finding
  pneumonia
  lung cancer
  pleural effusion

Answer 99

A normal finding

Bronchovesicular sounds are expected in this area of the chest. Pneumonia would cause crackles or no breathing sounds if there were consolidation. Lung cancer usually is not detected by auscultation. No breath sounds would be heard over a pleural effusion.

Question 100

he examiner notes a diaphragmatic excursion of 4 cm on the right side and 8 cm on the left side. What do these findings mean?
The patient may have a pleural effusion.
The patient may have a pneumothorax.
Asymmetric findings are common in well-conditioned adults.
This is a normal finding because the right lung is larger than the left lung.

Answer 100

The patient may have a pleural effusion.

Fluid in the pleural space can be detected by noting a difference in diaphragmatic excursion. A pneumothorax will be evidenced by decreased lung sounds and changes in percussion tone on the affected side. Measurements should be bilaterally equal.

Question 101

During an assessment, the nurse knows that expected assessment findings in the normal adult lung include the presence of what? (Select all that apply.)
Adventitious sounds and limited chest expansion
Increased tactile fremitus and dull percussion tones
Muffled voice sounds and symmetric tactile fremitus
Absent voice sounds and hyperresonant percussion tones
Symmetric chest
Resonant percussion tones
Expansion muffled voice sounds

Answer 101

Muffled voice sounds and symmetric tactile fremitus Symmetric chest
Resonant percussion tones
Expansion muffled voice sounds

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. The chest should fully expand. Percussion tones would be resonant in the normal assessment of an adult; voice sounds would be muffled.