Respiratory physical assessment ATI

Which expected breath sounds are heard over the largest portions of the lungs and are soft-sounding like wind blowing through trees?

a

Tracheal

b

Wheeze

c

Vesicular

d

Rales

Tracheal

This is heard over the trachea and is high-pitched

b

Wheeze

This is an abnormal breath sound and is a whistle sound

c

Vesicular

This is a normal breath sound that is heard over most of the lung fields with a soft sound like wind blowing through trees

d

Rales

This is an abnormal breath sound that is a crackling

The nurse is inspecting a client’s anterior chest. Which of the following findings should the nurse expect?

a

The ribs are sloping downward at an angle.

b

Rales noted along the lower aspects of the lungs.

c

Rib deformities felt at the thoracic level.

d

The spine is without deformities.

A
The ribs are sloping downward at an angle.

The expected findings of the anterior chest shape is the angle of the ribs in a downward slope with muscle tone dependent on the age, weight, shape and athletic build of the client.

b

Rales noted along the lower aspects of the lungs.

Rales is an unexpected finding found during auscultation, not inspection.

c

Rib deformities felt at the thoracic level.

Deformities of the ribs may be found during palpation.

d

The spine is without deformities.

The spine is inspected on the posterior chest, not the anterior chest.

A nurse is inspecting a client and documents that the spine is straight and the movement upon inspiration is symmetrical. Which of the following describes the location that the nurse is documenting?

a

The lateral chest

b

The posterior chest

c

The anterior chest

d

The abdomen

The lateral chest

The spine and inspiration are not assessed from the lateral chest.

b

The posterior chest

The posterior chest allows for inspection of the both the spine and symmetry.

c

The anterior chest

The anterior chest is the front of the client. Symmetry is able to be assessed but not the spine.

d

The abdomen

The abdomen is not part of the respiratory assessme

A nurse is preparing education material for a client to maintain a healthy respiratory status. Which of the following information should the nurse include in the materials?

Select all that apply.

a

Instruct and encourage the client to obtain the influenza vaccine

b

Inform the client that wearing a mask during the change of seasons prevents illness.

c

Counsel the client about smoking cessation

d

Educate the client that hand hygiene is the first line of defense to prevent illness.

A
Instruct and encourage the client to obtain the influenza vaccine

The nurse should instruct the client to have an annual flu vaccine to decrease the risk of getting influenza.

b

Inform the client that wearing a mask during the change of seasons prevents illness.

Wearing a mask during change of seasons is not a reasonable plan for illness prevention unless the client is immunocompromised.

c

Counsel the client about smoking cessation

The nurse should council the client the dangers of smoking. Smoking poses many health hazards including lung disease and lung cancer.

d

Educate the client that hand hygiene is the first line of defense to prevent illness.

The nurse should educate the client about the importance of good hand hygiene to decrease the risk of acquiring an illness

A nurse is caring for a client who is experiencing respiratory distress. Which of the following positions should the nurse assist the client into?

a

Trendelenburg

b

Lying flat on back

c

Tripod position

d

Low-Fowler's position

Trendelenburg

Trendelenburg position places the client's head lower than the remainder of the body which is elevated and inclined on a plane. This position causes the abdominal organs to push up toward the chest which can further compromise the client's breathing.

b

Lying flat on back

A position that promotes lung expansion and expands the lung area can help ease a client's respiratory distress. A supine position limits lung expansion.

c

Tripod position

The tripod position involves leaning over a table with arms placed on the table or sitting with the arms on the knees. This position allows for lung expansion which can help ease respiratory distress.

d

Low-Fowler's position

The low-Fowler's position will not promote lung expansion and can further contribute to the client's respiratory distress.

A nurse is assessing a client and notes minimal air movement with the client's inspirations. Which of the following should the nurse recognize as a contributing factor?

Select all that apply.

a

Pneumonia

b

Chest trauma

c

Fever

d

Decreased level of consciousness

A
Pneumonia

Pneumonia is an infection in the lungs that impairs the ability of the alveoli to exchange gases, resulting in minimal air movement.

b

Chest trauma

Chest trauma can limit the ability of the lungs to fully expand, thus limiting air movement.

c

Fever

A fever can result in tachypnea. However, it is not the cause of minimal air movement.

d

Decreased level of consciousness

A decreased level of consciousness can cause a client have shallow breathing with minimal air movement.

A nurse is caring for a client who is hyperventilating. The nurse should identify that which of the following circumstances can contribute to hyperventilation?

Select all that apply.

a

Nausea

b

Pain

c

Anxiety

d

Fear

A

Nausea

Nausea can contribute to hyperventilation, excess salivation, and emesis.

b

Pain

Pain is a subjective response that can cause a person to hyperventilate, regardless of the level of pain felt.

c

Anxiety

Anxiety can cause rapid breathing which can develop in to hyperventilation.

d

Fear

Fear can cause rapid breathing, which can cause hyperventilation.

A nurse is auscultating the lateral lobes of a client who has bronchitis. The nurse should document the sound as which of the following? (Click on the audio button to listen to the clip.)

•

Rhonchi

Wheeze

Coarse crackles

Stridor

Rhonchi

INCORRECT

Rhonchi is a continuous, loud, low-pitched, snoring-type sound heard during expiration. It is caused by fluid or mucus that accumulates in the larger airways.

Wheeze

~ CORRECT

My Answer

A respiratory wheeze is a whistling, high-pitched, musical sound made as air flows through narrowed passages. Wheezing can occur with conditions such as asthma and bronchitis because a client's airways are narrowed by edema.

Coarse crackles

INCORRECT

Crackles, or rales, are an intermittent rattling, crackling, popping, or bubbling sound. These sounds can be fine and high-pitched or coarse and low-pitched and are not cleared by coughing.

Stridor

INCORRECT

Stridor is a high-pitched crowing sound that is heard loudly in the neck area without a stethoscope. Stridor generally starts in the larynx or trachea and can be caused by swelling that then causes narrowing, either from sticky mucus or a foreign body lodged in the throat area. Stridor can be life-threatening.

A nurse is performing a head-to-toe assessment of a client. Which of the following findings indicate the client might be experiencing respiratory difficulty? (Select all that apply.)

•

• The client occasionally sighs.

• The client is sitting in a tripod position.

• The client's respiratory rate is 18/min.

• The client is using pursed lipped breathing.

• The client appears confused.

The client occasionally sighs is incorrect. An occasional sigh is an expected finding. Sighing allows the alveoli to expand. Frequent sighing can indicate respiratory difficulty.

The client is sitting in a tripod position is correct. A client might be sitting in a tripod position to use the abdominal, intercostal, and neck muscles to facilitate oxygen exchange. This is an unexpected finding that can indicate the client is having respiratory difficulty.

The client's respiratory rate is 18/min is incorrect. The expected finding for respiratory rate is 10 to 20/min. A client who is experiencing respiratory difficulty will have a higher rate per minute.

The client is using pursed lipped breathing is correct. Pursed lipped breathing is a technique of expiration used by clients who experience respiratory difficulty, such as those who have COPD. This is an unexpected finding.

The client appears confused is correct. Confusion is an unexpected finding and can indicate hypoxia, or a lack of oxygen delivery to the brain. The nurse should assess further to determine the origin of the client's confusion.

A charge nurse is observing a newly licensed nurse perform an anterior chest auscultation on a client. For which of the following actions should the charge nurse intervene?

The nurse asks the client to cough before beginning the auscultation.

The nurse is auscultating through the client's gown.

The nurse places the stethoscope on the intercostal spaces.

The nurse moves down the chest in a ladder sequence.

The nurse asks the client to cough before beginning the auscultation.

INCORRECT

Asking the client to cough before beginning the auscultation is a correct action. This allows the client to clear any mucus that could produce abnormal breath sounds.

The nurse is auscultating through the client's gown.

~ CORRECT

My Answer

The charge nurse should intervene because the stethoscope should be placed directly on the client's skin during auscultation.

Auscultating through clothing can produce crackling or other abnormal sounds and obstruct air movement.

The nurse places the stethoscope on the intercostal spaces.

INCORRECT

Placing the stethoscope on the intercostal spaces is a correct action to take during auscultation. Breath sounds cannot be heard properly moving through the rib bones. Therefore, the stethoscope should be placed between the ribs.

The nurse moves down the chest in a ladder sequence.

INCORRECT

Moving down the chest wall from side to side in a ladder sequence is a correct action to take when auscultating a client's anterior chest.

A nurse is caring for a client who is experiencing episodes of hyperventilation. Which of the following manifestations should the nurse expect during hyperventilation? (Select all that apply.)

Numbness and tingling of extremities

Decreased chest wall expansion

Lightheadedness

Periods of apnea

Chest pain

Numbness and tingling of extremities is correct. A client who is hyperventilating can show manifestations including numbness and tingling of the extremities, heart palpitations, chest pain, and lightheadedness.

Decreased chest wall expansion is incorrect. Clients who have shallow respirations have a decreased chest wall expansion. A client who is experiencing hyperventilation has respirations that are faster and deeper than usual. Other manifestations can include numbness and tingling of the extremities, heart palpitations, chest pain, and lightheadedness.

Lightheadedness is correct. A client who is hyperventilating can show manifestations including numbness and tingling of the extremities, heart palpitations, chest pain, and lightheadedness.

Periods of apnea is incorrect. A client who is experiencing hyperventilation has respirations that are faster and deeper than usual. Other manifestations can include numbness and tingling of the extremities, heart palpitations, chest pain, and lightheadedness.

Chest pain is correct. Clients who are hyperventilating have respirations that are faster and deeper than usual. A client who is hyperventilating can show manifestations including numbness and tingling of the extremities, heart palpitations, chest pain, and lightheadedness.

A nurse is reviewing the medical record of a client who was assessed as having a barrel chest resulting from COPD. Which of the following images shows a client who has a barrel chest?

CORRECT

A barrel chest is caused by hyperinflation of the lunes due to a disease process, such as COPD. It can also be associated with the normal aging process. The anterior, posterior to transverse diameter is equal, and the ribs, normally in a downward slope, lie horizontally. The client might sit in al tripod position to obtain adequate oxygen exchange.

INCORRECT

A tunnel chest nas a marked sunken sternum and costal carlare tnat usually begins at te second Intercostal Space. a runnel chest snould not

cause any respiratory distress.

INCORRECT

A standard chest has a rib cage that is angled slightly downward, as opposed to horizontal or full.

INCORRECT

My Answer

A pigeon chest, or pectus carinatum, describes a protrusion of the sternum with backward sloping of the ribs. It is considered a minor deformity that should not cause any respiratory distress and does not need to be corrected.

A nurse is caring for a client who is having difficulty breathing. Which of the following actions should the nurse take first?

Instruct the client to deep breathe and cough.

Provide the client with an incentive spirometer.

Elevate the head of the client's bed.

Reassess by auscultating the client's lungs.

• Instruct the client to deep breathe and cough.

INCORRECT

The nurse should instruct the client to deep breathe and cough, but according to evidence-based practice, there is another action that should be taken first.

Provide the client with an incentive spirometer.

INCORRECT

The nurse should provide the client with an incentive spirometer, but according to evidence-based practice, there is another action that should be taken first.

Elevate the head of the client's bed.

~ CORRECT

My Answer

According to evidence-based practice, the first action the nurse should take is to elevate the head of the client's bed. Raising the head of the bed to a semi-Fowler's or high-Fowler's position will allow for improved lung expansion, which can facilitate air and gas exchange.

Reassess by auscultating the client's lungs.

INCORRECT

The nurse should reassess by auscultating the client's lungs, but according to evidence-based practice, there is another action that should be taken first.

A nurse is caring for a client who is dying and is having periods of deep breathing alternating with periods of apnea. The nurse should identify this as which of the following types of breathing?

Thoracic breathing

Cheyne-Stokes breathing

Bradypnea

Kussmaul breathing

Thoracic breathing

INCORRECT

Thoracic breathing is an expected variation in which the chest rises and expands with inspiration and falls and contracts with expiration.

Cheyne-Stokes breathing

~ CORRECT

My Answer

Cheyne-Stokes breathing can occur if the central nervous system is grossly affected by lack of oxygen or disease progression. It appears to have a respiratory "start-stop" breathing pattern.

The client will have a deeper breath that might quicken, followed by hypoventilation and progression to apnea. This is an end-of-life breathing pattern.

Bradypnea

INCORRECT

Bradypnea indicates a respiratory rate of 10/min or less.

Kussmaul breathing

INCORRECT

Kussmaul breathing consists of respirations that are abnormally deep, regular, and increased in rate.

A nurse is auscultating the breath sounds of a client who has pneumonia and hears bronchial crackles. In which of the following areas of the chest is the nurse auscultating? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)

A is correct. Bronchial breath sounds are heard to the right and left of the trachea and larynx.

They can only be heard on the anterior chest.

B is incorrect. Bronchovesicular breath sounds are heard from the right and left major bronchi between the first and second intercostal space on the anterior chest and also between the scapulae on the posterior chest.

C is incorrect. Vesicular breath sounds are heard over a large percentage of the bilateral lung fields from the clavicle to the lower rib cage.

A nurse is providing discharge teaching regarding the influenza vaccine to a client who has COPD. Which of the following statements should the nurse make?

"It's just a small number of people that get the flu from receiving the vaccine."

"Call your provider immediately if you have any flu-like symptoms after receiving the vaccine."

"You should make every effort to receive a flu vaccine every year."

"The vaccine becomes effective immediately after the injection."

"It's just a small number of people that get the flu from receiving the vaccine."

INCORRECT

The nurse should explain to the client that it is a myth that the influenza vaccine can cause the client to develop influenza.

It takes up to 14 days for the influenza vaccine to become effective, so exposure to influenza prior to or shortly after being immunized can still result in illness. It is not recommended that people who are older than 49 years of age, or are immunocompromised, receive the live vaccine.

"Call your provider immediately if you have any flu-like symptoms after receiving the vaccine."

INCORRECT

The nurse should explain to the client that the influenza vaccination can cause mild influenza-like manifestations for a day or two following the injection. It is not necessary to notify the provider of these manifestations.

"You should make every effort to receive a flu vaccine every year."

CORRECT

The nurse should explain to the client that the Centers for Disease Control and Prevention recommends that everyone older than 6 months of age should receive an annual influenza vaccine. Influenza can cause serious respiratory complications, even death, especially in those who are immunocompromised.

"The vaccine becomes effective immediately after the injection."

INCORRECT

The nurse should explain to the client that it takes up to 14 days for the influenza vaccine to become effective.

The nurse is providing education to a client about tobacco smoking and smoking cessation. The statements that the nurse should make to the client include _______ and ______

The nurse should take actions when teaching the client about tobacco use and smoking cessation by making therapeutic and accurate statements. These statements include "Smoking is linked to various forms of cancer." And "It may take several attempts to finally stop smoking."

A charge nurse is teaching a newly licensed nurse how to recognize manifestations of decreased oxygenation in a client.

Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

"A client using thoracic breathing is experiencing a lack of oxygen."

"A pulse oximeter reading of 95% indicates respiratory distress."

"Clubbing of the fingers indicates a chronic state of impaired perfusion."

"A pinkish hue on the cheeks of a client with light skin tone indicates they are struggling to breathe."

"A client using thoracic breathing is experiencing a lack of oxygen."

INCORRECT

Thoracic breathing is an expected variation in which the chest rises and expands with inspiration and falls and contracts with expiration. It is not a sign of decreased oxygenation.

"A pulse oximeter reading of 95% indicates respiratory distress."

INCORRECT

A pulse oximeter reading of 95% is within the expected range. A pulse oximeter reading of less than 90% indicates decreased perfusion.

"Clubbing of the fingers indicates a chronic state of impaired perfusion."

~ CORRECT

My Answer

Clubbing of the ends of the fingers can indicate a chronic state of decreased oxygenation and perfusion.

"A pinkish hue on the cheeks of a client with light skin tone indicates they are struggling to breathe."

INCORRECT

A pinkish hue on the cheeks is an indication of adequate oxygenation in a client with light skin tone.

A nurse is providing teaching to a client who has a new diagnosis of asthma and reports a smoking history of 20 years. Which of the following statements should the nurse make when counseling the client about their tobacco use?

Select all that apply.

"Smoking is linked to various forms of cancer."

"There are no risks associated with exposure to secondhand smoke."

"It might take several attempts to finally stop smoking."

"Smoking will cause you to die years earlier than if you didn't smoke."

"There are pharmacologic therapies that can help a person stop smoking."

"Smoking is linked to various forms of cancer" is correct. Along with the development of respiratory disease, tobacco use is also associated with cancers of the colon, bladder, kidney, stomach, liver, and pancreas.

"There are no risks associated with exposure to secondhand smoke" is incorrect. The nurse should inform the client that exposure to secondhand smoke can lead to asthma, heart disease, lung cancer, and respiratory and ear infections.

"It might take several attempts to finally stop smoking" is correct. The nurse should inform the client that nicotine is highly addictive and that attempts at smoking cessation are often not successful the first time.

"Smoking will cause you to die years earlier than if you didn't smoke" is incorrect. The nurse should use therapeutic communication with the client and offer the client resources and a smoking cessation plan.

"There are pharmacologic therapies that can help a person stop smoking" is correct. The nurse should be prepared with a smoking cessation plan for the client that includes both cognitive and pharmacologic therapies.

A charge nurse is reviewing the documentation of a newly licensed nurse. Which of the following entries made by the newly licensed nurse is an example of correct documentation?

I cannot sleep at night because I get short of breath.

Client seems to not like certain staff members.

Clientic partner does not vicit the client enduch

Client's partner does not visit the client enough.

Inspiratory wheeze auscultated at left lateral chest.

I cannot sleep at night because I get short of breath.

INCORRECT

Any direct quotes by the client should be placed in quotation marks when documenting them in the medical record.

Client seems to not like certain staff members.

INCORRECT

Nurses should not offer personal opinions when documenting in the client's medical record. Any notes regarding of client behavior should be descriptive, clear, and concise.

Client's partner does not visit the client enough.

INCORRECT

The nurse should not offer personal judgments or opinions in the client's medical record.

Inspiratory wheeze auscultated at left lateral chest.

• CORRECT

My Answer

This entry is documented correctly. It is objective, descriptive, and based on facts. This information provides an accurate picture of the client's respiratory assessment for all providers.

A nurse in the emergency department is assessing a client who has experienced thoracic trauma from a motor vehicle crash. Which of the following findings is an indication of a pneumothorax?

The client's ribs slope downward at a 45° angle.

The client is making a high-pitched crowing sound that can be heard in the neck area.
The diameter of the client's chest appears barrel-like with horizontal ribs.
The client is experiencing unequal movement of the posterior chest.

The client's ribs slope downward at a 45° angle.

INCORRECT

This is an expected finding for a posterior chest.

The client is making a high-pitched crowing sound that can be heard in the neck area.

INCORRECT

This finding is describing stridor, which occurs with the narrowing of the larynx or trachea. It is a medical emergency.

The diameter of the client's chest appears barrel-like with horizontal ribs.

INCORRECT

This finding is describing a barrel chest, which occurs with COPD. The client will have the appearance of continuous inspiration due to hyperinflation of the lungs. A barrel chest can also be associated with normal aging.

The client is experiencing unequal movement of the posterior chest.

CORRECT

My Answer

When a pneumothorax, or collapsed lung, occurs, there is unequal expansion of the posterior chest. The client will be tachypneic with decreased or absent breath sounds on the affected side. A chest tube to reinflate the lung is required to reverse a pneumothorax.

A nurse is preparing to auscultate a client's posterior and lateral chest. In which order should the nurse perform the following actions? (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

1. Auscultate 8 cm (3 in) to one side of the spine around C7, then auscultate the other side of the spine in the same location.

2. Auscultate the lateral sides slightly below the axillary area, then down to the seventh or eighth rib.

3. Expose the posterior chest with the client sitting with their arms folded across their chest.

4. Auscultate down the spine, moving the stethoscope from one side to the other until reaching the lower thoracic spine.

3 Expose the posterior chest with the client sitting with their arms folded across their chest is the first step. The nurse should first expose the client's posterior chest to auscultate a client's posterior and lateral chest. With the client sitting, the nurse should ask the client to fold their arms across their chest.

1 Auscultate 8 cm (3 in) to one side of the spine around C7, then auscultate the other side of the spine in the same location is the second step. The nurse should begin auscultating 8 cm (3 in) to one side of the spine around C7, and then auscultate to the other side of the spine in the same location.

4. Auscultate down the spine, moving the stethoscope from one side to the other until reaching the lower thoracic spine is the third step. The nurse should next auscultate down the spine, moving the stethoscope from one side to the other until reaching the lower thoracic spine.

2 Auscultate the lateral sides slightly below the axillary area, then down to the seventh or eighth rib is the fourth step.The final step is to auscultate the lateral sides slightly below the axillary area, and then auscultate down to the seventh or eighth rib.

A nurse is assessing a client with a dark skin tone. In which of the following areas of the client's body should the nurse assess the client for adequate oxygenation? (Select all that apply.)

Cheeks

Nail beds

Oral mucosa

Sclerae

Nasal cavity

Cheeks is incorrect. Assessing a client's body for signs of adequate oxygenation is different depending on the skin tone of the client. A client with a light skin tone will have a pinkish hue to their cheeks.

Nail beds is correct. Clients with a dark skin tone and clients with a light skin tone will have pink nail beds if adequate amounts of oxygen are in the bloodstream.

Oral mucosa is correct. The nurse should inspect the oral mucosa of a client with a dark skin tone for adequate oxygenation.

Sclerae is incorrect. Assessing a client's sclerae does not give an indication of adequate oxygenation in the bloodstream.

Nasal cavity is incorrect. Assessing a client's nasal cavity does not give an indication of adequate oxygenation in the bloodstream.

A charge nurse is teaching a newly licensed nurse how to recognize a pleural friction rub. Which of the following descriptions should the nurse use to describe a pleural friction rub? (Select all that apply.)

Coarse grating tone

Intermittent popping or bubbling sound

Heard on inspiration and expiration

Snoring sound on expiration

Pain with breathing

Coarse grating tone is correct. A pleural friction rub occurs because of inflammation of the pleurae. It is a low-pitched, coarse grating tone that sounds like rubbing two pieces of leather together. It can be heard on inspiration and expiration and is very painful.

Intermittent popping or bubbling sound is incorrect. An intermittent popping or bubbling sound describes crackles, or rales. The sounds occur when inhaled air collides with secretions in the trachea and bronchi. They cannot be cleared by coughing.

Heard on inspiration and expiration is correct. A pleural friction rub occurs because of inflammation of the pleurae. It is a low-pitched, coarse grating tone that sounds like rubbing two pieces of leather together. It can be heard on inspiration and expiration and is very painful.

Snoring sound on expiration is incorrect. A snoring sound on expiration is a description of rhonchi. Rhonchi occurs when fluid or mucus accumulates in the larger airways and can be heard on expiration. Rhonchi can be cleared by coughing.

Pain with breathing is correct. A pleural friction rub occurs because of inflammation of the pleurae. It is a low-pitched, coarse grating tone that sounds like rubbing two pieces of leather together. It can be heard on inspiration and expiration and is very painful.

A nurse is admitting a client who has a new diagnosis of COPD. Which of the following information documented by the nurse is subjective data? (Select all that apply.)



Pulse oximeter reading is 89% on 0z 2 L/min via nasal cannula.
Report from client says they sleep while propped on two pillows at night.
Client says they quit smoking 2 years ago.
Respiratory rate increases to 28/min when client ambulates to restroom.

Client states, "Being short of breath all of the time is making me depressed."

Pulse oximeter reading is 89% on 02 2 L/min via nasal cannula is incorrect. The recorded results of a monitoring tool, such as a pulse oximeter, is objective information.

Report from client says they sleep while propped on two pillows at night is correct. This information is reported by the client and is therefore subjective.

Client says they quit smoking 2 years ago is correct. This information is reported by the client and is therefore subjective.

Respiratory rate increases to 28/min when client ambulates to restroom is incorrect. This information is observed and measured by the nurse and is therefore objective.

Client states, "Being short of breath all of the time is making me depressed" is correct. This information is reported by the client and is therefore subjective.