Which of these statements is true regarding the vertebra prominens? The vertebra prominens is:
ANS: the spinous process of C7.
The spinous process of C7 is the vertebra prominens. It 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 an
When performing a respiratory assessment on a patient, the nurse notices a costal angle of approximately 90 degrees. This characteristic is:
ANS: a normal finding in a healthy adult.
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, as in emphysema
When assessing a patient's lungs, the nurse recalls that the left lung:
ANS: consists of two lobes.
The left lung has two lobes, and the right lung has three lobes. The right lung is shorter than the left lung because of the underlying liver. The left lung is narrower than the right lung because the heart bulges to the left.
Which statement about the apices of the lungs is true? The apices of the lungs:
ANS: extend 3 to 4 cm above the inner third of the clavicles.
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.
During an examination of the anterior thorax, the nurse keeps in mind that the trachea bifurcates anteriorly at the:
ANS: sternal angle.
The sternal angle marks the site of tracheal bifurcation into the right and left main bronchi; it corresponds with the upper border of the atria of the heart, and it lies above the fourth thoracic vertebra on the back.
During an assessment, the nurse knows that expected assessment findings in the normal adult lung include the presence of:
ANS: absent voice sounds and hyperresonant percussion tones.
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 primary muscles of respiration include the:
ANS: diaphragm and intercostals.
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 inspirati
A 65-year-old patient with a history of heart failure comes to the clinic with complaints of "being awakened from sleep with shortness of breath." Which action by the nurse is most appropriate?
ANS: Assess for other signs and symptoms of paroxysmal nocturnal dyspnea.
The patient is experiencing paroxysmal nocturnal dyspnea: being awakened from sleep with shortness of breath and the need to be upright to achieve comfort.
When assessing tactile fremitus, the nurse recalls that it is normal to feel tactile fremitus most intensely over which location?
ANS: Between the scapulae
Normally, fremitus is most prominent between the scapulae and around the sternum. These are sites where the major bronchi are closest to the chest wall. Fremitus normally decreases as one progress down the chest because more tiss
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? "Tactile fremitus:
ANS: is caused by sounds generated from the larynx."
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 ter
During percussion, the nurse knows that a dull percussion note elicited over a lung lobe most likely results from:
ANS: increased density of lung tissue.
A dull percussion note indicates an abnormal density in the lungs, as with pneumonia, pleural effusion, atelectasis, or tumor. Resonance is the expected finding in normal lung tissue.
The nurse is observing the auscultation technique of another nurse. The correct method to use when progressing from one auscultatory site on the thorax to another is ____ comparison.
ANS: side-to-side
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 incorrect.
When auscultating the lungs of an adult patient, the nurse notes that over the posterior lower lobes low-pitched, soft breath sounds are heard, with inspiration being longer than expiration. The nurse interprets that these are:
ANS: vesicular breath sounds and are normal in that location.
Vesicular breath sounds are low-pitched, soft sounds with inspiration being longer than expiration. These breath sounds are expected over peripheral lung fields where air flows through smaller
The nurse is auscultating the chest in an adult. Which technique is correct?
ANS: Use the diaphragm of the stethoscope held firmly against the chest.
The diaphragm of the stethoscope held firmly on the chest is the correct way to auscultate breath sounds. The patient should be instructed to breathe through his or her mouth, a litt
The nurse is percussing over the lungs of a patient with pneumonia. The nurse knows that percussion over an area of atelectasis in the lungs would reveal:
ANS: dullness.
A dull percussion note signals an abnormal density in the lungs, as with pneumonia, pleural effusion, atelectasis, or tumor.
During auscultation of the lungs, the nurse expects decreased breath sounds to be heard in which situation?
ANS: When the bronchial tree is obstructed
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.
The nurse notes hyperresonant percussion tones when percussing the thorax of an infant.
ANS: consider this a normal finding.
The percussion note of hyperresonance occurs normally in the infant and young child, owing to the relatively thin chest wall. Anything less than hyperresonance would have the same clinical significance as would dullnes
The nurse knows that a normal finding when assessing the respiratory system of an elderly adult is:
ANS: decreased mobility of the thorax.
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.
A mother brings her 3-month-old infant to the clinic for evaluation of a cold. She tells the nurse that he 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
ANS: recognize that these are serious signs and contact the physician.
The infant is an obligatory nose breather until the age of 3 months. Normally there is no flaring of the nostrils and no sternal or intercostal retraction. Marked retractions of the st
When assessing the respiratory system of a 4-year-old child, which of these findings would the nurse expect?
ANS: The presence of bronchovesicular breath sounds in the peripheral lung fields
Bronchovesicular breath sounds in the peripheral lung fields of the infant and young child up to age 5 or 6 years are a normal finding. Their thin chest walls with underdeve
When inspecting the anterior chest of an adult, the nurse should include which assessment?
ANS: The shape and configuration of the chest wall
Inspection of the anterior chest includes shape and configuration of the chest wall; assessment of the patient's level of consciousness, skin color and condition; quality of respirations; presence or abse
The nurse knows that auscultation of fine crackles would most likely be noticed in:
ANS: the immediate newborn period.
Fine crackles are commonly heard in the immediate newborn period as a result of the opening of the airways and clearing of fluid. Persistent fine crackles would be noticed with pneumonia, bronchiolitis, or atelectasis.
During an assessment of an adult, the nurse has noted unequal chest expansion and recognizes that this occurs in which situation?
ANS: When part of the lung is obstructed or collapsed
Unequal chest expansion occurs when part of the lung is obstructed or collapsed, as with pneumonia, or when guarding to avoid postoperative incisional pain or atelectasis.
During auscultation of the lungs of an adult patient, the nurse notices the presence of bronchophony. The nurse should assess for signs of which condition?
ANS: Pulmonary consolidation
Pathologic conditions that increase lung density, such as pulmonary consolidation, will enhance transmission of voice sounds, such as bronchophony. See Table 18-7.
The nurse is reviewing the characteristics of breath sounds. Which statement about bronchovesicular breath sounds is true? They are:
ANS: expected near the major airways.
Bronchovesicular sounds are heard over major bronchi where fewer alveoli are located: posteriorly, between the scapulae, especially on the right; anteriorly, around the upper sternum in the first and second intercosta
The nurse is listening to the breath sounds of a patient with severe asthma. Air passing through narrowed bronchioles would produce which of these adventitious sounds?
ANS: Wheezes
Wheezes are caused by air squeezed or compressed through passageways narrowed almost to closure by collapsing, swelling, secretions, or tumors, such as with acute asthma or chronic emphysema.
A patient has a long history of chronic obstructive pulmonary disease. During the assessment, the nurse is most likely to observe which of these?
ANS: An anteroposterior-to-transverse diameter ratio of 1:1
An anteroposterior-to-transverse diameter of 1:1 or "barrel chest" is seen in individuals with chronic obstructive pulmonary disease because of hyperinflation of the lungs. The ribs are more hori
A teenage patient comes to the emergency department with complaints of an inability to breathe and a sharp pain in the left side of his chest. The assessment findings include cyanosis, tachypnea, tracheal deviation to the right, decreased tactile fremitus
ANS: a pneumothorax.
With a pneumothorax, free air in the pleural space causes partial or complete lung collapse. If the pneumothorax is large, then tachypnea and cyanosis are seen. Unequal chest expansion, decreased or absent tactile fremitus, tracheal d
An adult patient with a history of allergies comes to the clinic complaining of wheezing and difficulty in breathing when working in his yard. The assessment findings include tachypnea, use of accessory neck muscles, prolonged expiration, intercostal retr
ANS: asthma.
Asthma is allergic hypersensitivity to certain inhaled particles that produces inflammation and a reaction of bronchospasm, which increases airway resistance, especially during expiration. Increased respiratory rate, use of accessory muscles,
The nurse is assessing the lungs of an older adult. Which of these describes normal changes in the respiratory system of the older adult?
ANS: The lungs are less elastic and distensible, which decreases their ability to collapse and recoil.
In the aging adult the lungs are less elastic and distensible, which decreases their ability to collapse and recoil. There is a decreased vital capacity
A woman in her 26th week of pregnancy states that she is "not really short of breath" but feels that she is aware of her breathing and the need to breathe. What is the nurse's best reply?
ANS: "What you are experiencing is normal. Some women may interpret this as shortness of breath, but it is a normal finding and nothing is wrong."
During pregnancy, the woman may develop an increased awareness of the need to breathe. Some women may interp
When considering the biocultural differences in the respiratory systems, the nurse knows that which statement is true?
ANS: The largest chest volumes are found in whites.
The largest chest volumes are found, in descending order, in whites, then African-Americans, Asians, and Native Americans. Even when the shorter height of Asians is considered, their chest volume remains
A 35-year-old recent immigrant is being seen in the clinic for complaints of a cough that is associated with rust-colored sputum, low-grade afternoon fevers, and night sweats for the past 2 months. The nurse's preliminary analysis, based on this history,
ANS: tuberculosis.
Sputum is not diagnostic alone, but some conditions have characteristic sputum production. Tuberculosis often produces rust-colored sputum in addition to other symptoms of night sweats and low-grade afternoon fevers. See Table 18-8.
A 70-year-old patient is being seen in the clinic for severe exacerbation of his heart failure. Which of these findings is the nurse most likely to observe in this situation?
ANS: Shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, ankle edema
Heart failure often presents with increased respiratory rate, shortness of breath on exertion, orthopnea, paroxysmal nocturnal dyspnea, nocturia, ankle edema, and pallor in lig
A patient comes to the clinic complaining of a cough that is worse at night but not as bad during the day. The nurse recognizes that this may indicate:
ANS: postnasal drip or sinusitis.
A cough that occurs mainly at night may indicate postnasal drip or sinusitis. Exposure to irritants at work causes an afternoon or evening cough. Smokers experience early morning coughing. Coughing associated with acute i
During a morning assessment, the nurse notices that the patient's sputum is frothy and pink. Which condition could this finding indicate?
ANS: Pulmonary edema
Sputum alone is not diagnostic, but some conditions have characteristic sputum production. Pink, frothy sputum indicates pulmonary edema (or it may be a side effect of sympathomimetic medications). Croup is associated with a "barking
During auscultation of breath sounds, the nurse should use the stethoscope correctly, in which of the following ways?
ANS: Listen to at least one full respiration in each location.
During auscultation of breath sounds with a stethoscope, it is important to listen to one full respiration in each location. During the examination, the nurse should monitor the breathing and
A patient has been admitted to the emergency department with a possible medical diagnosis of pulmonary embolism. The nurse expects to see which assessment findings related to this condition?
ANS: Chest pain that is worse on deep inspiration, dyspnea
Findings for pulmonary embolism include chest pain that is worse on deep inspiration, dyspnea, apprehension, anxiety, restlessness, PaO2 less than 80, diaphoresis, hypotension, crackles, and wheez
During palpation of the anterior chest wall, the nurse notices a coarse, crackling sensation over the skin surface. On the basis of these findings, the nurse suspects:
ANS: crepitus.
Crepitus is a coarse, crackling sensation palpable over the skin surface. It occurs in subcutaneous emphysema when air escapes from the lung and enters the subcutaneous tissue, as after open thoracic injury or surgery.
The nurse is auscultating the lungs of a patient who had been sleeping and notices short, popping, crackling sounds that stop after a few breaths. The nurse recognizes that these breath sounds are:
ANS: atelectatic crackles, and that they are not pathologic.
One type of adventitious sound, atelectatic crackles, is not pathologic. They are short, popping, crackling sounds that sound like fine crackles but do not last beyond a few breaths. When sectio
A patient has been admitted to the emergency department for a suspected drug overdose. His respirations are shallow, with an irregular pattern, with a rate of 12 per minute. The nurse interprets this respiration pattern as which of the following?
ANS: Hypoventilation
Hypoventilation is characterized by an irregular, shallow pattern, and can be caused by an overdose of narcotics or anesthetics. Bradypnea is slow breathing, with a rate less than 10 respirations per minute. See Table 18-4 for descrip
A patient with pleuritis has been admitted to the hospital and complains of pain with breathing. What other key assessment finding would the nurse expect to find upon auscultation?
ANS: Friction rub
A patient with pleuritis will exhibit a pleural friction rub upon auscultation. This is the sound made when pleurae become inflamed and rub together during respiration. The sound is superficial, coarse, and low-pitched, as if two pieces
The nurse is assessing voice sounds during a respiratory assessment. Which of these findings indicates a normal assessment? Select all that apply.
ANS: Voice sounds are faint, muffled, and almost inaudible when the patient whispers "one, two, three" in a very soft voice.
When the patient speaks in a normal voice, the examiner can hear a sound but cannot distinguish exactly what is being said.
As the