Question 1

A 65-year-old patient with a history of heart failure comes to the clinic stating "I keep waking up from sleep with shortness of breath." Which action by the nurse is most appropriate?

Accepted Answer

Being awakened from sleep with shortness of breath is a symptom of paroxysmal nocturnal dyspnea. The nurse should assess for other signs and symptoms of paroxysmal nocturnal dyspnea. Paroxysmal nocturnal dyspnea is usually relieved by sitting upright.

Question 2

When assessing the respiratory system of a 4-year-old child, which of these findings would the nurse expect?

Accepted Answer

Bronchovesicular breath sounds in the peripheral lung fields of the infant and young child up to age 5 or 6 years are normal findings. Their thin chest walls with underdeveloped musculature do not dampen the sound, as do the thicker chest walls of adults; therefore, breath sounds are loud and harsh. Crepitus is not a normal or expected finding in a child or any age patient. Although the technique of measuring diaphragmatic excursion using percussion is no longer recommended, you would still expect to see diaphragmatic excursion (movement of the diaphragm) in a 4-year-old child. The normal respiratory rate for a 4-year-old child is 20 to 24, so a respiratory rate of 40 while at rest would be tachypnea.

Question 3

During auscultation of the lungs, the nurse expects decreased breath sounds to be heard in which situation?

Accepted Answer

Decreased or absent breath sounds occur when the bronchial tree is obstructed, as in emphysema, and when sound transmission is obstructed, as in pleurisy, pneumothorax, or pleural effusion. Although there may be decreased breath sounds when adventitious sounds are heard or with consolidation, it is not expected. Decreased breath sounds are also not expected with whispered pectoriloquy.

Question 4

Where does the trachea bifurcate on the anterior chest?

Accepted Answer

The sternal angle marks the site of tracheal bifurcation into the right and left main bronchi; it corresponds with the upper borders of the atria of the heart, and it lies above the fourth thoracic vertebra on the back.

Question 5

During percussion, the nurse hears a dull percussion note elicited over a lung lobe. What is the most likely cause of this finding?

Accepted Answer

A dull percussion note indicates an abnormal density in the lungs, as with pneumonia, pleural effusion, atelectasis, or a tumor. Resonance is the expected finding in normal lung tissue.

Question 6

The nurse is auscultating the chest in an adult. Which technique is correct?

Accepted Answer

Firmly holding the diaphragm of the stethoscope against the chest is the correct way to auscultate breath sounds. The patient should be instructed to breathe through his or her mouth, a little deeper than usual, but not to hyperventilate. The patient should be instructed to take breaths a little deeper than usual but not to hyperventilate and to breathe through his or her mouth, not nose. The diaphragm not the bell should be used to auscultate breath sounds and holding the diaphragm of the stethoscope firmly against the chest is the correct way to auscultate breath sounds.

Question 7

During an assessment, the nurse knows that expected assessment findings in the normal adult lung include which findings?

Accepted Answer

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.

Question 8

When inspecting the anterior chest of an adult, the nurse should include which assessment?

Accepted Answer

Inspection of the anterior chest includes shape and configuration of the chest wall; assessment of the patient's level of consciousness and the patient's skin color and condition; quality of respirations; presence or absence of retraction and bulging of the intercostal spaces; and use of accessory muscles. Symmetric chest expansion is assessed by palpation. Diaphragmatic excursion is assessed by percussion of the posterior chest. Breath sounds are assessed by auscultation. Diaphragmatic excursion is assessed by percussion of the posterior chest, not observation of the anterior chest; symmetric chest expansion is assessed by palpation, not by observation; and breath sounds are assessed by auscultation. Inspection of the anterior chest includes shape and configuration of the chest wall; assessment of the patient's level of consciousness and the patient's skin color and condition; quality of respirations; presence or absence of retraction and bulging of the intercostal spaces; and use of accessory muscles.

Question 9

When auscultating the lungs of an adult patient, the nurse notes that low-pitched, soft breath sounds are heard over the posterior lower lobes, with inspiration being longer than expiration. How should the nurse interpret these findings?

Accepted Answer

Vesicular breath sounds are low-pitched, soft sounds with inspiration being longer than expiration. These breath sounds are expected over the peripheral lung fields where airflows through smaller bronchioles and alveoli.

Question 10

Which of these statements is true regarding the vertebra prominens?

Accepted Answer

The spinous process of C7 is the vertebra prominens and is the most prominent bony spur protruding at the base of the neck. Counting ribs and intercostal spaces on the posterior thorax is difficult because of the muscles and soft tissue. The vertebra prominens is easier to identify and is used as a starting point in counting thoracic processes and identifying landmarks on the posterior chest. The vertebra prominens is not opposite the interior border of the scapula or next to the manubrium of the sternum. Instead, the vertebra prominens is the spinous process of C7. It is the most prominent bony spur protruding at the base of the neck, thus, it is easy to identify and palpate. Because counting ribs and intercostal spaces on the posterior thorax is difficult due to the number of muscles and soft tissue, the vertebra prominens is used as a starting point in counting thoracic processes and identifying landmarks on the posterior chest.

Question 11

Which is a normal finding when assessing the respiratory system of an older adult?

Accepted Answer

The costal cartilages become calcified with aging, resulting in a less mobile thorax. Chest expansion may be somewhat decreased, and the chest cage commonly shows an increased anteroposterior diameter. The costal cartilages become calcified with aging, resulting in a less mobile thorax and thus also a slight decrease, not increase, in thoracic expansion. The chest cage commonly shows an increased, not a decreased, anteroposterior diameter and bronchovesicular breath sounds are not found throughout the lungs.

Question 12

What are the primary muscles of respiration?

Accepted Answer

The major muscle of respiration is the diaphragm. The intercostal muscles lift the sternum and elevate the ribs during inspiration, increasing the anteroposterior diameter. Expiration is primarily passive. Forced inspiration involves the use of other muscles, such as the accessory neck muscles-sternomastoid, scaleni, and trapezii muscles. Forced expiration involves the abdominal muscles.

Question 13

Which statement about the apices of the lungs is true?

Accepted Answer

The apex of the lung on the anterior chest is 3 to 4 cm above the inner third of the clavicles. On the posterior chest, the apices are at the level of C7.

Question 14

A mother brings her 3-month-old infant to the clinic for evaluation of a cold. She tells the nurse that he has had "a runny nose for a week." When performing the physical assessment, the nurse notes that the child has nasal flaring and sternal and intercostal retractions. What should the nurse do next?

Accepted Answer

The infant is an obligatory nose breather until the age of 3 months. Normally no flaring of the nostrils and no sternal or intercostal retraction occurs. Significant retractions of the sternum and intercostal muscles and nasal flaring indicate increased inspiratory effort, as in pneumonia, acute airway obstruction, asthma, and atelectasis; therefore, immediate referral to the physician is warranted. These signs do not indicate heart failure, and an assessment of the infant's feeding is not a priority at this time. These signs are not normal, do not indicate heart failure, and an assessment of the infant's feeding is not a priority at this time.

Question 15

When assessing a patient's lungs, what should the nurse recall about the left lung?

Accepted Answer

The left lung has two lobes and is longer and narrower than the right lung. It is narrower than the right lung because the heart bulges to the left. The right lung has three lobes and is shorter than the left lung because of the underlying liver. The posterior chest is almost all lower lobes.

Question 16

The nurse is observing the auscultation technique of a student nurse. What is the correct method to use when progressing from one auscultatory site on the thorax to another?

Accepted Answer

Side-to-side comparison is most important when auscultating the chest. The nurse should listen to at least one full respiration in each location. The other techniques are not correct.

Question 17

When assessing tactile fremitus, the nurse recalls that it is normal to feel tactile fremitus most intensely over which location?

Accepted Answer

Normally fremitus is most prominent between the scapulae and around the sternum. These sites are where the major bronchi are closest to the chest wall. Fremitus normally decreases as one progresses down the chest because more tissue impedes sound transmission.

Question 18

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?

Accepted Answer

Fremitus is a palpable vibration. Sounds generated from the larynx are transmitted through patent bronchi and the lung parenchyma to the chest wall where they are felt as vibrations. Crepitus is the term for air in the subcutaneous tissues.

Question 19

When performing a respiratory assessment on a patient, the nurse notices a costal angle of approximately 90 degrees. What should the nurse recognize about this finding?

Accepted Answer

The right and left costal margins form an angle where they meet at the xiphoid process. Usually, this angle is 90 degrees or less. The angle increases when the rib cage is chronically overinflated (barrel chest), as in emphysema.This is a normal finding and is not associated with kyphosis or indicative of pectus excavatum.

Question 20

The nurse is percussing over the lungs of a patient with pneumonia. If the patient has atelectasis, what sound will the nurse hear?

Accepted Answer

A dull percussion note signals an abnormal density in the lungs, as with pneumonia, pleural effusion, atelectasis, or a tumor. Tympany is a hollow drum-like sound normally found with percussion over the intestines in the abdomen. Resonance is a low-pitched, clear, hollow sound that predominates in healthy lung tissue. Hyperresonance is a lower-pitched, booming sound found when too much air is present such as in emphysema or pneumothorax. An abnormal density in the lungs, such as atelectasis, pneumonia, pleural effusion, or a tumor would produce a dull note when percussed.

Quiz 19: Thorax and Lungs