Exam 3 chapter 11 Flashcards
(101 cards)
1
Q
What requires adequate oxygenation for optimal functioning?
A
Metabolism, motion, tissue integrity, sleep, and nutrition
2
Q
Ventilation
A
Process of moving gases in and out of the lungs by inspiration and expiration
3
Q
Diffusion
A
The process by which oxygen and carbon dioxide move from areas of high concentration to areas of lower concentration
4
Q
There are three main structures within the thorax (chest)
A
The mediastinum and the right and left pleural cavities
5
Q
The mediastinum is positioned in the?
A
Middle of the chest. Within it lie the heart, the arch or aorta, the superior vena cava, the lower esophagus, and the traches
6
Q
The pleural cavities contain?
A
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
7
Q
The right lung has? The left lung has?
A
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
8
Q
Most of the respiratory system is protected by the?
A
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
9
Q
The eleventh and twelfth ribs are?
A
Unattached anteriorly and are called floating ribs
-tips of the eleventh ribs are located in the posterior thorax
10
Q
The adult sternum is about 7 inches (17cm) long and has three components:
A
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
11
Q
Primary muscles of breathing
A
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
12
Q
During inspiration air is drawn in through the mouth or nose and passes through the pharynx and larynx to reach the?
A
trachea, a flexible tube approximately 4 inches (10cm) long in the adult
13
Q
Structures that make up the upper respiratory airway
A
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
14
Q
The lower airway consists of the?
A
Left and right main stem bronchi, the segmental and subsegmental bronchi, the terminal bronchioles, and alveoli
15
Q
The trachea splits into a?
A
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
16
Q
Present health status: Do you have chronic illnesses?
A
Many chronic illnesses can cause symptoms that affect the respiratory system, including heart disease or renal disease, which may cause pulmonary edema
17
Q
An increased frequency of allergies may indicate?
A
The onset of new allergies or ineffective therapy for respiratory disease
18
Q
Individuals who have no difficulty breathing until they are active may have?
A
Pulmonary or heart disease that limits the availability of oxygen needed during exertion
19
Q
Risk factors for lung cancer
(M)=modifiable risk
A
- 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
20
Q
Home environment factors that may affect breathing
A
- 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
21
Q
Recording tobacco use
A
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
22
Q
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?
A
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)
23
Q
A description of a cough may provide clues to the cause.
A
- Viral pneumonia causes a dry cough
- Bacterial pneumonia causes a productive cough
24
Q
The frequency of sputum production and the time of day most sputum is produced should be explored.
A
- 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)
25
Documenting the appearance of the sputum is important. Some conditions have characteristic sputum production
- 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
26
The consistency of sputum may be described as?
Thin, thick, gelatinous, sticky, frothy
- pink, frothy sputum with dyspnea is associated with pulmonary edema
- Thick sputum is commonly associated with cystic fibrosis
27
Foul smelling (fetid) sputum is typically associated with
bacterial pneumonia, lung abscess, or bronchiectasis
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?
1) Lung infection
| 2) Asthma
29
Orthopnea
Difficulty breathing when the individual is lying down
30
Paroxysmal nocturnal dyspnea
SOB that awakens the individual in the middle of the night, usually in a panic with the feeling of suffocation
31
Describing dyspnea
Count the words the the patient can say between breaths
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?
Radiating pain to the jaw, left arm, and back and women report SOB, diaphoresis, nausea, epigastric pain, and fatigue
33
A sharp, abrupt pain associated with deep breathing may be an indication of?
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
34
atelectasis
Collapse of alveoli
35
Indications of respiratory distress include an?
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
36
Respirations normal: An expected variation is the abdominal breathing pattern. Men tend to use?
```
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
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37
Respiration Abnormal findings
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
38
Nail beds should be
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
39
Abnormal findings for nails, skin, ips
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
40
Expected findings: Inspect the posterior thorax for shape, symmetry, and muscle development.
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
41
Patients with emphysema may have a?
Barrel shaped chest due to chronic air trapping in the alveoli
42
Expected findings for auscultating the posterior and lateral thoraxes for breath sounds
Breath sounds should be clear over the posterior and lateral thoraxes. Vesicular and bronchovesicular breath sounds are expected
43
Abnormal findings for breath sounds
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
44
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Bronchial
Pitch
Intensity
Duration: Inspiration and expiration
Expected location
Abnormal location
```
Pitch: High
Intensity: Loud
Duration: Inspiration and expiration: Insp < Exp 1:2
Expected location: Over trachea
Abnormal location: Over peripheral lung fields
45
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Bronchovesicular
Pitch
Intensity
Duration: Inspiration and expiration
Expected location
Abnormal location
```
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
46
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Vesicular
Pitch
Intensity
Duration: Inspiration and expiration
Expected location
Abnormal location
```
Pitch: Low
Intensity: Soft
Duration: Inspiration and expiration: Insp > Exp 2.5:1
Expected location: Peripheral lung fields
Abnormal location: not applicable
47
Vesicular breath sounds should be heard over?
Almost all of the posterior & lateral thoraxes.
48
Bronchovesicular breath sounds should be heard over the?
Upper center area of the posterior thorax between the vertebrae between the scapulae
49
The term stridor is more prominent over the neck than the chest and is used to describe a?
Harsh, high-pitched sound associated with breathing that is often caused by laryngeal or tracheal obstruction
50
Crackles (previously called rales)
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
51
Wheeze (also called sibilant wheeze)
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
52
Rhonchi (also called sonorous wheeze)
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
53
Pleural friction rub
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
54
Abnormal findings for anterior thorax
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)
55
The anteroposterior (AP) diameter of the chest should be approximately
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
56
Abnormal findings for the anterior thorax (anteroposterior (AP)
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
57
Vesicular breath sounds should be heard throughout the?
Anterior thorax, including the apex of the lungs above the clavicles
58
Bronchovesicular breath sounds are expected sounds heard over the?
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
59
Bronchial breath sounds are the expected sounds heard over the?
Trachea and the area immediately above the manubrium
60
Abnormal findings: when a pleural friction rub is heard, you can distinguish the source (lung or heart) by asking the patient to?
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
61
Expected findings: the posterior thoracic muscles
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
62
Expected findings: anterior thoracic muscles
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
63
Abnormal findings for posterior and anterior thoracic muscles
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
64
Palpate the posterior and anterior thoracic walls for vocal (tactile) fremitus. Perform when?
Congestion, obstruction, or compression of lung tissue is suspected
65
Fremitus provides information about the density of underlying lung tissue and thorax. Vocal fremitus is a ?
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
66
The fremitus should feel?
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
67
Abnormal findings for fremitus
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
68
Abnormal findings for trachea
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
69
Advanced practice techniques
- percuss thorax for tone
- percuss the thorax for diaphragmatic excursion
- auscultate the thorax for vocal sounds (vocal resonance)
70
How to document expected findings
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
71
Assessing neonates and infants requires use of?
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
72
Assessing older adults
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
73
Acute bronhitis
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
74
Pneumonia
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
75
Pleural effusion
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
76
Asthma
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
77
Emphysema
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
78
Chronic bronchitis
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
79
Pneumothorax
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)
80
Hemothorax
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
81
Atelectasis
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%
82
Lung cancer
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
83
A nurse suspects a viral infection or upper respiratory allergies when the patient describes the sputum as being which color?
clear
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
4
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?
Prolonged expiration with an occasional wheeze in the right lower lobe
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?
Rhonchi
87
Which question gives the nurse further information about the patient's complaint of chest pain?
"How would you describe the chest pain?"
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?
Decreased breath sounds on auscultation
89
How does the nurse palpate the chest for tenderness, bulges, and symmetry?
With the palmar surface of fingers of both hands, feels the consistency of the skin over the chest and the alignment of vertebrae
90
Which breath sounds are expected over the posterior chest of an adult?
Vesicular
91
Narrowing of the bronchi creates which advenitious sound?
Wheeze
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?
Ask patient to cough then repeat the auscultation
93
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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.
```
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.
94
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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
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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.
95
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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
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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.
96
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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
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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.
97
The nurse percusses a patient’s chest and feels dullness. The nurse suspects which diagnosis?
Emphysema
Pneumonia
Bronchiectasis
Chronic obstructive pulmonary disease (COPD)
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.
98
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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
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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.
99
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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
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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.
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.
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.
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
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.
