Lung Assessment

Question 1

Name the anterior reference lines

Answer 1

Midclavicular and medial line

Question 2

Pt is dehydrated. What sound might you hear when auscultating lungs?

Answer 2

Pleural rub (when you step on snow)

Question 3

Pt has pneumonia. Pt complains of pain when breathing.

Answer 3

Pleuritis

Question 4

When I lay down, I feel like I cannot breathe. I can place pillows behind me and that helps.

Answer 4

Orthopnea

Question 5

What is orthopnea?

Answer 5

Difficulty breathing when laying down

Question 6

What is parozysmal nocturnal dyspnea?

Answer 6

In the middle of night, the pt has trouble sleeping. And they wake up in the middle of the night. Feeling like they were not breathing.

Question 7

I am having trouble breathing. This is known as…

Answer 7

Dyspnea

Question 8

I snore and sometimes I feel like I have to gasp for a breath

Answer 8

Sleep apnea

Question 9

You have a pt who has no history of respiratory issues and is basically healthy. The nurses is auscultating and hearing adventitious lung sounds. What do you ask the pt to do?

Answer 9

Ask patient to cough

Question 10

Order of the lung assessment?

Answer 10

Inspection, Palpation, Percussion, Auscultation

Question 11

Patient has a barrel chest, what assessment phase is this?

Answer 11

Inspection

Question 12

Patient is cyanotic, what assessment phase is this?

Answer 12

Inspection

Question 13

The patient’s chest rises and falls evenly, what assessment phase is this?

Answer 13

Inspection

Question 14

You are observing your pt during respirations and you notice their chest appears to sink in just below the neck, under the breastbone, rib cage, and intercostal spaces. Why is this happening?

Answer 14

The patient is compensating by attempting to bring in more air into the lungs

Question 15

Kyphosis

Answer 15

Hunchback. May be related to osteoporosis in the elderly.

Question 16

When we palpate, what are we looking for?

Answer 16

To check for crepitus pain, tenderness, edema, proper motions

Question 17

When palpating, you feel a crackling sensation. What could this be?

Answer 17

Crepitus

Question 18

What is tactile fremitus?

Answer 18

Vibrations

Question 19

You assess for tactile fremitus. You place your hands on their back ad ask them to say “99.” Why do you do this?

Answer 19

You want it to feel the same on both sides

Question 20

What does it mean if there is unequal vibrations when palpating for tactile fremitus?

Answer 20

Consolidation on one side of the lung.

Question 21

What sounds could we hear when we percuss?

Answer 21

Tone (hollow sounds on both sides),
Hyperresonance (air trapped in the lungs),
Dullness (i.e., over a solid or liquid tumor)
Resonance (low pitch sound over healthy tissue)
Diaphragmatic excursion (measuring the movement of the diaphragm)

Question 22

What is emphysema?

Answer 22

Loss of elasticity in alveioli, therefore, air gets trapped

Question 23

What sound do you hear when the pt has emphysema

Answer 23

Resonance

Question 24

Usually we are listening to…

Answer 24

vesicular sounds

Question 25

Bronchial sounds are heard during

Answer 25

expiration

Question 26

Vesicular sounds are heard during

Answer 26

inspiration

Question 27

Bronchovesicular sounds are heard during

Answer 27

both

Question 28

You ask your pt to repeat "99" while you auscultate their chest. What is this called?

Answer 28

Bronchophony

Question 29

During auscultation, you notice it is easy to under the "99" sound. Should you concerned?

Answer 29

Yes. May indicate a tumor or pneumonia

Question 30

You ask your pt to repeat "E" while you auscultate their chest. What is this called?

Answer 30

Egophany

Question 31

You ask your pt to repeat "E" while you auscultate their chest. The E sounds like A. Is this concerning?

Answer 31

Yes. Possible fluid in the lungs.

Question 32

You ask your pt to whisper "123" while you auscultate their chest. What is this called?

Answer 32

Whisper pectoriloquy

Question 33

During your respiratory assessment, you auscultate a high pitched sound during inspiration. What do you document this as?

Answer 33

Stridor

Question 34

Pt is admitted to Ed with exacerbation of asthma. What is the most prominent adventitious sound you are likely to hear and what causes it?

Answer 34

Wheezing. Inflammation and bronchospasm.

Question 35

Pt has been admitted into the ICU with a TBI (traumatic brain injury). Their respirations are sometimes deep, sometimes shallow, and occasional apnea. How will you document this?

Answer 35

Biot

Question 36

Pt who is in hospice is now deep and rapid breathing, followed by periods of apnea. How will you document this?

Answer 36

Cheyne Stokes

Question 37

A pt is brought into the ED in diabetic ketoacidosis (DKA) They appear to be hyperventilating. How will you document this?

Answer 37

Kussmauls

Question 38

Common variations in older adults

Answer 38

Increased chest diameter Kyphosis Decreased thoracic expansion Use of accessory muscles to exhale At risk for fractures (osteoporosis) Experiencing dyspnea with aging lungs Decreased ability to cough

Question 39

Difference between kyphosis and scoliosis?

Answer 39

Kyphosis is the rounding of the thoracic spine Scoliosis is a lateral deviation of the spine

Question 40

If someone has long term clubbing, can it be indicative of pulmonary difficulties?

Answer 40

Yes, chronic

Question 41

What are symptoms of pulmonary edema?

Answer 41

dyspnea, restlessness, cyanosis, pink frothy sputum

Question 42

It is difficult to palpate as it lies behind the clavicle

Answer 42

First rib

Question 43

A loud, low-pitched, hollow sound normally percussed over an area that is part air and part solid, which is expected over normal lung fields.

Answer 43

Resonance

Question 44

Very loud, low-pitched sound that is normally heard in lungs with a lot of air such as in emphysema.

Answer 44

Hyper-resonance

Question 45

Loud, high-pitched, drum-like sound that is heard over an air-filled structure, such as the stomach

Answer 45

Tympany

Question 46

Medium-pitched, thud-like sound that is percussed over solid tissue such as the liver.

Answer 46

Dullness

Question 47

During palpation of a client’s organs, the nurse palpates the spleen by applying pressure between 2.5 and 5 cm. The nurse is performing what kind of palpation

Answer 47

Deep palpation