PrepU: Assessing Thorax & Lungs Flashcards
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
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 _______.
chronic bronchitis
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?
Ask the client if they have recently exerted themselves.
When assessing the posterior chest, what is a starting point for counting ribs and interspaces?
12th rib
What would the nurse expect to hear when auscultating the Lungs of a client diagnosed with pleuritis?
Friction rub
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?
“Please say the number ‘ninety-nine’ for me.”
The nurse auscultates the base of the lungs to assess for what reason?
It is where fluid occurs with pulmonary edema.
The nurse is preparing to auscultate the client’s thorax. What action is the priority during this component of assessment?
Listen at each site for at least one complete respiratory cycle.
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
-History of radiation exposure
-Exposure to asbestos at work
The nurse is preparing to auscultate the client’s thorax. What action is the priority during this component of assessment?
Listen at each side for at least one complete respiratory cycle.
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?
The client will have a loss of involuntary respiratory control.
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 _______.
suprasternal notch
When assessing the apices of the lungs, the nurse would locate them at which position?
Slightly above the clavicle
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
A high-pitched crowing sound from the upper airway results from the tracheal or laryngeal spasm and is called what?
Stridor
The spinous process termed the vertebra prominens is in which cervical vertebra?
Seventh
The spinous process termed the vertebra prominens is in which cervical vertebra?
Seventh
The apex of each lung is located at the…
…area slightly above the clavicle.
Which accessory muscles are most important when considering inspiratory breathing needs during exercise?
Sternocleidomastoids
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.
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…
…a foreign body obstruction.
The clavicles extend from the acromion of the scapula to the part of the sternum termed the _______.
manubrium
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?
“I just quit smoking today.”
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
