PrepU: Assessing Thorax & Lungs

Question 1

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?

Answer 1

Severe brain damage

Question 2

The nurse assesses an adult client and observes that the client’s breathing pattern is very labored and noisy, with occasional coughing. The nurse should refer the client to a health care provider for possible _______.

Answer 2

chronic bronchitis

Question 3

The nurse is assessing a client’s respiratory rate and rhythm during the beginning of a shift. The client’s rate is 29 breaths per minute. How should the nurse respond to this assessment finding?

Answer 3

Ask the client if they have recently exerted themselves.

Question 4

When assessing the posterior chest, what is a starting point for counting ribs and interspaces?

Answer 4

12th rib

Question 5

What would the nurse expect to hear when auscultating the Lungs of a client diagnosed with pleuritis?

Answer 5

Friction rub

Question 6

While assessing the health of a client’s respiratory system, the nurse is palpating the frimitous. What instructions should the nurse provide to the client during this component of assessment?

Answer 6

“Please say the number ‘ninety-nine’ for me.”

Question 7

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

Answer 7

It is where fluid occurs with pulmonary edema.

Question 8

The nurse is preparing to auscultate the client’s thorax. What action is the priority during this component of assessment?

Answer 8

Listen at each site for at least one complete respiratory cycle.

Question 9

A 60-year-old male client presents to the health clinic with a 3 week history of cough, pluritic chest pain, increasing fatigue and intermittent fevers, which data collected in this history. Should the nurse recognize as risk factors for the development of lung cancer? Select all that applies.

-High-fat diet
-Moderate alcohol consumption -Smokeless tobacco
-History of radiation exposure
-Exposure to asbestos at work

Answer 9

-History of radiation exposure
-Exposure to asbestos at work

Question 10

The nurse is preparing to auscultate the client’s thorax. What action is the priority during this component of assessment?

Answer 10

Listen at each side for at least one complete respiratory cycle.

Question 11

A client has sustained a brain stem injury and is being treated in the intensive care unit. What would the nurse need to consider when assessing this client’s respiratory status?

Answer 11

The client will have a loss of involuntary respiratory control.

Question 12

In pulpiting the chest of a client, a nurse feels a U-shaped invitation on the superior border of the manubrium. The nurse recognizes this landmark as the _______.

Answer 12

suprasternal notch

Question 13

When assessing the apices of the lungs, the nurse would locate them at which position?

Answer 13

Slightly above the clavicle

Question 14

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?

Answer 14

Coarse crackles

Question 15

A high-pitched crowing sound from the upper airway results from the tracheal or laryngeal spasm and is called what?

Answer 15

Stridor

Question 16

The spinous process termed the vertebra prominens is in which cervical vertebra?

Answer 16

Seventh

Question 17

The spinous process termed the vertebra prominens is in which cervical vertebra?

Answer 17

Seventh

Question 18

The apex of each lung is located at the…

Answer 18

…area slightly above the clavicle.

Question 19

Which accessory muscles are most important when considering inspiratory breathing needs during exercise?

Answer 19

Sternocleidomastoids

Question 20

The client reports severe pain when breathing in deeply. The description suggests to the nurse that the client is experiencing which respiratory condition?

Answer 20

Inflammation of the parietal pleura.

Question 21

A young toddler is brought to the emergency room by their parents. The parents State that the child was playing on the floor with toys and suddenly began to wheeze. They report no recent illnesses. The nurse suspects that the most likely cause of the wheezing is…

Answer 21

…a foreign body obstruction.

Question 22

The clavicles extend from the acromion of the scapula to the part of the sternum termed the _______.

Answer 22

manubrium

Question 23

The nurse is assessing a client’s progress in smoking cessation according to the Stages of Change Model. Which statement indicates that the client is in the Action stage?

Answer 23

“I just quit smoking today.”

Question 24

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?

Answer 24

Fluid in the alveoli

Question 25

While examining a client, the nurse observes the client’s chest to be barrel shaped. The nurse would interpret this as indicating what?

Answer 25

Emphysema

Question 26

A triage nurse is working in the emergency department of a busy hospital. 4 clients have recently been admitted. Client A has an arrhythmia diagnosed as atrial fibrillation; client B is in chronic congestive heart failure; client C is assessed and found to have a probable pulmonary embolism; client D reports of chest pain relieved by nitroglycerin and rest. Which client would be the nurse’s highest priority?

Answer 26

Client C because cardiac emergencies that necessitate rapid assessment and intervention include acute coronary syndromes, acute decompensated heart failure, hypertensive crisis, cardiac tamponade, unstable cardiac arrhythmias, cardiogenic shock, systemic or pulmonary embolism, and aortic dissection.