Question 1

Which type of breath sound would the nurse expect to auscultate over most of the lung fields in a healthy patient?

Accepted Answer

Vesicular breath sounds are the normal sounds heard over most lung fields. They are soft, low-pitched, and heard throughout inspiration and the beginning of expiration, indicating healthy lung tissue.

Question 2

Which physical assessment technique would be used to identify egophony?

Accepted Answer

Egophony is identified through auscultation, where the healthcare provider listens to the patient's lungs with a stethoscope to detect changes in voice sounds.

Question 3

Which physical assessment technique would be used to identify dullness?

Accepted Answer

Percussion is the technique used to identify dullness by tapping on the body surface to determine the underlying structure's density. Dullness typically indicates the presence of fluid or solid tissue beneath the surface, such as in the case of a pleural effusion or a solid organ enlargement.

Question 4

The nurse is assessing an older adult patient who is admitted to the hospital with aspiration pneumonia of the right middle lobe. Which approaches will best facilitate assessment of the right middle lobe of the lung?

Accepted Answer

The right middle lobe of the lung is best assessed through the anterior and lateral chest walls because of its anatomical position. It does not extend to the posterior chest, making the anterior and lateral approaches most effective for assessment.

Question 5

Which physical assessment technique would be used to identify sternal retraction?

Accepted Answer

Inspection is the correct technique for identifying sternal retraction, as it involves visually examining the chest area for any abnormalities in movement, such as the inward movement of the sternum during inhalation, which can indicate respiratory distress or other respiratory conditions.

Question 6

Which physical assessment technique would best determine chest excursion?

Accepted Answer

Palpation is the best technique to assess chest excursion, as it involves physically feeling the chest as the patient breathes, allowing the examiner to assess the movement and symmetry of the chest wall during respiration.

Question 7

Because the patient has pneumonia, the nurse assesses for abnormal voice sounds. The patient has clearer transmission of spoken voice sounds. This is an example of which type of voice sound?

Accepted Answer

Bronchophony is characterized by the clearer and louder transmission of spoken sounds through the lung fields, often due to lung consolidation, as seen in pneumonia.

Question 8

Which standard view is typically inappropriate when conducting a respiratory assessment?

Accepted Answer

The superior view, which looks at the body from above, is typically inappropriate for a respiratory assessment because it does not provide a clear view of the lungs or chest wall movements. Anterior, posterior, and lateral views are more useful for examining lung expansion, symmetry, and detecting abnormalities.

Question 9

The nurse detects crackles when auscultating a patient's chest. Which statement accurately characterizes crackles?

Accepted Answer

Crackles, also known as rales, are abnormal lung sounds characterized by discontinuous clicking or rattling sounds. They are primarily heard during inspiration because this is when the small airways and alveoli (that are collapsed or contain fluid) open or pop, creating the crackling sound. This distinguishes them from other types of lung sounds that may be heard over different phases of the respiratory cycle or in different parts of the lung.

Question 10

Which physical assessment technique would be used to identify rales?

Accepted Answer

Rales, also known as crackles, are abnormal lung sounds that are detected through auscultation using a stethoscope.

Question 11

The patient develops a pleural effusion, so a chest tube is inserted. The nurse detects crepitus at the insertion site. Which conclusion by the nurse is most appropriate?

Accepted Answer

Crepitus at the insertion site of a chest tube is indicative of air leakage into the subcutaneous tissue, a condition known as subcutaneous emphysema. This occurs when air escapes from the lung or chest wall into the subcutaneous layer, causing a crackling sensation when palpated.

Question 12

The nurse is assessing a patient who is admitted with the diagnosis of pleuritis. Auscultation of the patient's thorax reveals a pleural friction rub. How can the nurse differentiate this sound from other abnormal breath sounds?

Accepted Answer

Pleural friction rubs are unique because they can be heard during both inspiration and expiration and are not affected by coughing, distinguishing them from other respiratory sounds that might change with coughing or be heard primarily during one phase of respiration.

Question 13

Which physical assessment technique would be used to identify wheezing?

Accepted Answer

Wheezing is identified through auscultation, which involves listening to the sounds of the body, typically using a stethoscope, to assess the airways and lungs.

Question 14

The nurse is assessing a patient diagnosed with consolidation pneumonia. Which type of breath sounds would the nurse expect to auscultate over the affected area?

Accepted Answer

Bronchial breath sounds are expected over areas of consolidation, such as in pneumonia, because the dense lung tissue conducts sound more efficiently, making the breath sounds more pronounced and similar to those heard over the trachea.

Question 15

Which physical assessment technique would be used to identify tactile fremitus?

Accepted Answer

Tactile fremitus is assessed through palpation, where the healthcare provider feels the vibrations transmitted through the patient's chest as they speak.

Question 16

The nurse notes scattered rhonchi when auscultating the patient's chest. How do rhonchi differ from crackles?

Accepted Answer

Rhonchi are low-pitched, continuous sounds that are produced by secretions in the larger airways. They are typically heard during both inspiration and expiration and are not affected by coughing. Crackles, on the other hand, are high-pitched, discontinuous sounds that are produced by the opening of small airways. They are typically heard only during inspiration and are affected by coughing.

Question 17

When assessing for cyanotic changes, central cyanosis may be distinguished from peripheral cyanosis. Which location does the nurse use to assess for central cyanosis?

Accepted Answer

Central cyanosis is best assessed in areas with a high vascularity that are not affected by peripheral blood flow changes, such as the mucous membranes. This includes the lips, tongue, and oral mucosa. Peripheral cyanosis, on the other hand, is typically observed in the extremities like the fingers, toes, and ear lobes.

Question 18

Which physical assessment technique would be used to determine the AP:lateral ratio?

Accepted Answer

The AP:lateral ratio, which refers to the anteroposterior (front to back) diameter compared to the lateral (side to side) diameter of the chest, is assessed through inspection. This is a visual examination to determine if the chest has a normal shape or if it exhibits signs of conditions like barrel chest, often seen in chronic obstructive pulmonary disease (COPD).

Quiz 5: Assessing the Respiratory System