Thorax & Lungs Ch.18 ?s Flashcards
Which of these statements is true regarding the vertebra prominens? The vertebra prominens is:
A) the spinous process of C7.
B) usually not palpable in most individuals.
C) opposite the interior border of the scapula.
D) located next to the manubrium of the sternum.
a
When performing a respiratory assessment on a patient, the nurse notices a costal angle of approximately 90 degrees. This characteristic is:
A) seen 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.
c
When assessing a patient’s lungs, the nurse recalls that the left lung:
A) consists of two lobes.
B) is divided by the horizontal fissure.
C) consists primarily of an upper lobe on the posterior chest.
D) is shorter than the right lung because of the underlying stomach.
a
Which statement about the apices of the lungs is true? The apices of the lungs:
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.
b
During an examination of the anterior thorax, the nurse keeps in mind that the trachea bifurcates anteriorly at the: A) costal angle. B) sternal angle. C) xiphoid process. D) suprasternal notch.
b
During an assessment, the nurse knows that expected assessment findings in the normal adult lung include the presence of:
A) adventitious sounds and limited chest expansion.
B) increased tactile fremitus and dull percussion tones.
C) muffled voice sounds and symmetrical tactile fremitus.
D) absent voice sounds and hyperresonant percussion tones.
c
The primary muscles of respiration include the:
A) diaphragm and intercostals.
B) sternomastoids and scaleni.
C) trapezius and rectus abdominis.
D) external obliques and pectoralis major.
a
A 65-year-old patient with a history of heart failure comes to the clinic with complaints of “being awakened from sleep with shortness of breath.” Which action by the nurse is most appropriate?
A) Obtain a detailed history of the patient’s allergies and 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 this is normal and will probably resolve within the next week.
c
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) Fifth intercostal space, MAL D) Over the lower lobes, posterior side
a
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? “Tactile fremitus:
A) is caused by moisture in the alveoli.”
B) indicates that there is air in the subcutaneous tissues.”
C) is caused by sounds generated from the larynx.”
D) reflects the blood flow through the pulmonary arteries.”
c
During percussion, the nurse knows that a dull percussion note elicited over a lung lobe most likely results from: A) shallow breathing. B) normal lung tissue. C) decreased adipose tissue. D) increased density of lung tissue.
d
The nurse is observing the auscultation technique of another nurse. The correct method to use when progressing from one auscultatory site on the thorax to another is \_\_\_\_ comparison. A) side-to-side B) top-to-bottom C) posterior-to-anterior D) interspace-by-interspace
a
When auscultating the lungs of an adult patient, the nurse notes that over the posterior lower lobes low-pitched, soft breath sounds are heard, with inspiration being longer than expiration. The nurse interprets that these are:
A) sounds normally auscultated over the trachea.
B) bronchial breath sounds and are normal in that location.
C) vesicular breath sounds and are normal in that location.
D) bronchovesicular breath sounds and are normal in that location.
c
The nurse is auscultating the chest in an adult. Which technique is correct?
A) Instruct the patient to take deep, rapid breaths.
B) Instruct the patient to breathe in and out through his or her nose.
C) Use the diaphragm of the stethoscope held firmly against the chest.
D) Use the bell of the stethoscope held lightly against the chest to avoid friction.
c
The nurse is percussing over the lungs of a patient with pneumonia. The nurse knows that percussion over an area of atelectasis in the lungs would reveal: A) dullness. B) tympany. C) resonance. D) hyperresonance.
a
During auscultation of the lungs, the nurse expects decreased breath sounds to be heard in which situation?
A) When the bronchial tree is obstructed
B) When adventitious sounds are present
C) In conjunction with whispered pectoriloquy
D) In conditions of consolidation, such as pneumonia
a
- The nurse knows that a normal finding when assessing the respiratory system of an elderly adult is:
A) increased thoracic expansion.
B) decreased mobility of the thorax.
C) a decreased anteroposterior diameter.
D) bronchovesicular breath sounds throughout the lungs.
b
- When inspecting the anterior chest of an adult, the nurse should include which assessment?
A) Diaphragmatic excursion
B) Symmetric chest expansion
C) The presence of breath sounds
D) The shape and configuration of the chest wall
d
- During an assessment of an adult, the nurse has noted unequal chest expansion and recognizes that this occurs in which situation?
A) 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
b
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) Airway obstruction B) Emphysema C) Pulmonary consolidation D) Asthma
c
The nurse is reviewing the characteristics of breath sounds. Which statement about bronchovesicular breath sounds is true? They are:
A) musical in quality.
B) usually pathological.
C) expected near the major airways.
D) similar to bronchial sounds except that they are shorter in duration.
c
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) Bronchial sounds C) Bronchophony D) Whispered pectoriloquy
a
A patient has a long history of chronic obstructive pulmonary disease. During the assessment, the nurse is most likely to observe which of these?
A) Unequal chest expansion
B) Increased tactile fremitus
C) Atrophied neck and trapezius muscles
D) An anteroposterior-to-transverse diameter ratio of 1:1
d
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. The nurse interprets that these assessment findings are consistent with: A) bronchitis. B) a pneumothorax. C) acute pneumonia. D) an asthmatic attack.
b
