Question 1

The nurse is assessing a 52-year-old patient admitted with aspiration pneumonia and a history of excessive alcohol consumption.The patient has been deteriorating and has developed sepsis.The nurse identifies the following findings indicating he likely has acute respiratory distress syndrome (ARDS): (Select all that apply.)

Accepted Answer

(ARDS occurs when an acute pulmonary insult (trauma, gastric acid aspiration, shock, sepsis) damages the alveolar capillary membrane, leading to increased permeability of the pulmonary capillaries and the alveolar epithelium and to pulmonary edema.Gross examination (autopsy) would show dark red, firm, airless tissue, with some alveoli collapsed, and hyaline membranes lining the distended alveoli.
Subjective: Acute onset of dyspnea, apprehension.
Inspection: Restlessness; disorientation; rapid, shallow breathing; productive cough; thin, frothy sputum; retractions of intercostal spaces and sternum.Decreased PaO?, blood gases show respiratory alkalosis, radiographs show diffuse pulmonary infiltrates, a late sign is cyanosis.
Palpation: Hypotension.
Auscultation: Tachycardia.
Adventitious sounds: Crackles, rhonchi.

Question 2

A patient with pleuritis has been admitted to the hospital and complains of pain with breathing.Upon auscultation, the nurse notes coarse, low-pitched sounds with a grating quality and documents them as:

Accepted Answer

Coarse, low-pitched sounds with a grating quality are characteristic of a friction rub, which is commonly heard in patients with pleuritis. Stridor is a high-pitched, crowing sound heard with inspiration and indicates upper airway obstruction. Crackles are fine, crackling sounds heard with inspiration and can indicate fluid in the lungs. Wheezing is a high-pitched, musical sound heard with expiration and can indicate narrowing of the airways.

Question 3

The nurse is assessing a 65-year-old patient who has smoked a pack of cigarettes a day for the past 40 years.The nurse identifies the following findings indicating that the patient likely has emphysema: (Select all that apply.)

Accepted Answer

Cigarette smoking accounts for 80-90% of cases of emphysema.
Inspection: Increased anteroposterior diameter; barrel chest; use of accessory muscles to aid respiration; tripod position; shortness of breath, especially on exertion; respiratory distress; tachypnea
Palpation: Decreased tactile fremitus and chest expansion
Percussion: Hyper-resonance; decreased diaphragmatic excursion
Auscultation: Decreased breath sounds; expiration may be prolonged; muffling of heart sounds as a result of overdistension of lungs
Adventitious sounds: Usually, none; occasional wheezing

Question 4

The nurse is assessing voice sounds during a respiratory assessment.Which of these findings indicates a normal assessment? (Select all that apply.)

Accepted Answer

As a patient repeatedly says "ninety-nine," normally the examiner hears voice sounds but cannot distinguish what is being said.If a clear "ninety-nine" is auscultated, then it could indicate increased lung density, which enhances the transmission of voice sounds, which is a measure of bronchophony.When a patient says a long "ee-ee-ee" sound, normally the examiner also hears a long "ee-ee-ee" sound through auscultation, which is a measure of egophony.If the examiner hears a long "aaaaaa" sound instead, this sound could indicate areas of consolidation or compression.With whispered pectoriloquy, as when a patient whispers a phrase such as "one-two-three," the normal response when auscultating voice sounds is to hear sounds that are faint, muffled, and almost inaudible.If the examiner clearly hears the whispered voice, as if the patient is speaking through the stethoscope, then consolidation of the lung fields may exist.

Quiz 19: Thorax and Lungs

A patient with pleuritis has been admitted to the hospital and complains of pain with breathing.Upon auscultation, the nurse notes coarse, low-pitched sounds with a grating quality and documents them as:

The nurse is assessing a 65-year-old patient who has smoked a pack of cigarettes a day for the past 40 years.The nurse identifies the following findings indicating that the patient likely has emphysema: (Select all that apply.)

The nurse is assessing voice sounds during a respiratory assessment.Which of these findings indicates a normal assessment? (Select all that apply.)