Respiratory assessment

During inspection of the posterior chest, the nurse should assess for:

A) symmetric expansion.

B) symmetry of shoulders and muscles.

C) tactile fremitus.

D) diaphragmatic excursion.

During inspection of the posterior chest, the nurse should assess for:

A) symmetric expansion.

B) symmetry of shoulders and muscles.

C) tactile fremitus.

D) diaphragmatic excursion.

ANS: B) symmetry of shoulders and muscles.

During inspection of the posterior chest, the nurse should inspect for symmetry of shoulders and muscles, configuration of the thoracic cage, and skin characteristics. Symmetric expansion and tactile fremitus are assessed with palpation; diaphragmatic excursion is assessed with percussion.

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The nurse hears bilateral loud, long, and low tones when percussing over the lungs of a 4-year-old child. The nurse should:

a. Palpate over the area for increased pain and tenderness.

b. Ask the child to take shallow breaths and percuss over the area again.

c. Immediately refer the child because of an increased amount of air in the lungs.

d. Consider this a normal finding for a child this age and proceed with the examination.

ANS: D

Percussion notes that are loud in amplitude, low in pitch, of a booming quality, and long in duration are normal over a child’s lung (See Table 9-1)

A patient has suddenly developed shortness of breath and appears to be in significant respiratory distress. After calling the physician and placing the patient on oxygen, which of these actions is best for the nurse to take when further assessing the patient?

a. Count the patient’s respirations

b. Bilaterally percuss the thorax, noting any differences in percussion tones

c. Call for a chest x-ray study, and wait for the results before beginning an assessment

d. Inspect the thorax for any new masses and bleeding associated with respirations

ANS: B

Percussion is always available, portable, and offers instant feedback regarding changes in underlying tissue density, which may yield clues of the patient’s physical status.

The nurse is preparing to assess a hospitalized patient who is experiencing significant shortness of breath. How should the nurse proceed with the assessment?

a. The patient should lie down to obtain an accurate cardiac, respiratory, and abdominal assessment.

b. A thorough history and physical assessment information should be obtained from the patient’s family member.

c. A complete history and physical assessment should be immediately performed to obtain baseline information.

d. Body areas appropriate to the problem should be examined and then the assessment completed after the problem has been resolved.

ANS: D

Both altering the position of the patient during the examination and collecting a mini-database by examining the body areas appropriate to the problem may be necessary in this situation. An assessment may be completed later after the distress-causing issue is resolved

The nurse is teaching the nursing students to palpate the vertebra prominens when beginning posterior thoracic assessment of a patient. The students will:

a. Look for the spinous process of C7.

b. Usually not be able to palpate this on most individuals.

c. Find the interior border of the scapula.

d. Locate this next to the manubrium of the sternum.

ANS: A

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.

When performing a respiratory assessment on a patient, the nurse notes a costal angle of approximately 90 degrees. This characteristic is:

a. Observed in patients with kyphosis.

b. Indicative of pectus excavatum.

c. A normal finding in a healthy adult.

d. An expected finding in a patient with a barrel chest.

ANS: C

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 recognizes that the left lung:

a. Consists of two lobes.

b. Is divided by the horizontal fissure.

c. Primarily consists of an upper lobe on the posterior chest.

d. Is shorter than the right lung because of the underlying stomach.

ANS: A

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. The posterior chest is almost all lower lobes

The nurse landmarks the apices of the lungs to:

a. Be at the level of the second rib anteriorly.

b. Extend 3 to 4 cm above the inner third of the clavicles.

c. Be located at the sixth rib anteriorly and the eighth rib laterally.

d. Rest on the diaphragm at the fifth intercostal space in the midclavicular line (MCL).

ANS: B

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 is aware that the trachea bifurcates anteriorly at the:

a. Costal angle.

b. Sternal angle.

c. Xiphoid process.

d. Suprasternal notch.

ANS: B

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

During an assessment, the nurse knows that expected assessment findings in the normal adult lung include the presence of:

a. Adventitious sounds and limited chest expansion.

b. Increased tactile fremitus and dull percussion tones.

c. Muffled voice sounds and symmetrical tactile fremitus.

d. Absent voice sounds and hyper-resonant percussion tones.

ANS: C

Normal lung findings include symmetrical chest expansion, resonant percussion tones, vesicular breath sounds over the peripheral lung fields, muffled voice sounds, and no adventitious sounds

The primary respiratory muscles engaged in normal inspiration include the:

a. Diaphragm and intercostals.

b. Sternomastoid and scalene.

c. Trapezius and rectus abdominis

d. External obliques and pectoralis major.

ANS: A

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, scalene, and trapezius muscles. Forced expiration involves the abdominal muscles

During assessment of the patient’s posterior chest for lung sounds, the nurse will auscultate the right lung for the:

a. Apex of the lung.

b. Upper and lower lobes.

c. Lower lobe, because the upper lobe is too small.

d. Upper, middle, and lower lobes.

ANS: B

The posterior chest is almost all lower lobe. The upper lobes occupy a smaller band of tissue from their apices at T1 down to T3 or T4. At this level, the lower lobes begin, and their inferior border reaches down to the level of T10 on expiration and to T12 on inspiration. The right middle lobe does not project onto the posterior chest at all.

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?

a. Obtain a detailed health history of the patient’s allergies and a history of asthma

b. Recommend that the patient sleep on his or her right side to facilitate ease of respirations

c. Assess for other signs and symptoms of paroxysmal nocturnal dyspnea

d. Assure the patient that paroxysmal nocturnal dyspnea is normal and will probably resolve within the next week

ANS: C

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 normally feel tactile fremitus most intensely:

a. Between the scapulae.

b. Third intercostal space, MCL.

c. Fifth intercostal space, midaxillary line (MAL).

d. Over the lower lobes, posterior side.

ANS: A

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

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”:

a. “Is caused by moisture in the alveoli.”

b. “Indicates that air is present in the subcutaneous tissues.”

c. “Is caused by sounds generated from the larynx.”

d. “Reflects the blood flow through the pulmonary arteries.”

ANS: C

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.

During percussion, the nurse knows that a dull percussion note elicited over a lung lobe most likely results from:

a. Shallow breathing.

b. Normal lung tissue.

c. Decreased adipose tissue.

d. Increased density of lung tissue.

ANS: D

A dull percussion note indicates an abnormal density in the lungs, as with pneumonia, pleural effusion, atelectasis, or a tumour. 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.

a. Side-to-side

b. Top-to-bottom

c. Posterior-to-anterior

d. Interspace-by-interspace

ANS: A

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

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. The nurse interprets these sounds as:

a. Normally auscultated over the trachea.

b. Bronchial breath sounds, which are normal in that location.

c. Vesicular breath sounds, which are normal in that location.

d. Bronchovesicular breath sounds, which are normal in that location.

ANS: C

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 air flows through smaller bronchioles and alveoli

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

a. Instructing the patient to take deep, rapid breaths

b. Instructing the patient to breathe in and out through his or her nose

c. Firmly holding the diaphragm of the stethoscope against the patient’s skin

d. Lightly holding the bell of the stethoscope over the gown to avoid friction

ANS: C

Firmly holding the diaphragm of the stethoscope against the skin of the chest is the correct way to auscultate breath sounds and decrease extraneous sounds from the gown. The patient should be instructed to breathe through his or her mouth, a little deeper than usual, but not to hyperventilate.

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 will reveal:

a. Dullness.

b. Tympany.

c. Resonance.

d. Hyper-resonance.

ANS: A

A dull percussion note signals an abnormal density in the lungs, as with pneumonia, pleural effusion, atelectasis, or a tumour

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

a. When the bronchial tree is obstructed

b. When adventitious sounds are present

c. In conjunction with whispered pectoriloquy

d. In conditions of consolidation, such as pneumonia

ANS: A

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 knows that a normal finding when assessing the respiratory system of an older adult is:

a. Increased thoracic expansion.

b. Decreased mobility of the thorax.

c. Decreased anteroposterior diameter.

d. Bronchovesicular breath sounds throughout the lungs.

ANS: B

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 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. The nurse’s next action should be to:

a. Assure the mother that these signs are normal symptoms of a cold.

b. Recognize that these are serious signs, and contact the physician.

c. Ask the mother if the infant has had trouble with feedings.

d. Perform a complete cardiac assessment because these signs are probably indicative of early heart failure.

ANS: B

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

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

a. Crepitus palpated at the costochondral junctions

b. No diaphragmatic excursion as a result of a child’s decreased inspiratory volume

c. Presence of bronchovesicular breath sounds in the peripheral lung fields

d. Irregular respiratory pattern and a respiratory rate of 40 breaths per minute at rest

ANS: C

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

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

a. Diaphragmatic excursion

b. Symmetrical chest expansion

c. Presence of breath sounds

d. Shape and configuration of the chest wall

ANS: D

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 colour and condition; quality of respirations; presence or absence of retraction and bulging of the intercostal spaces; and use of accessory muscles. Symmetrical chest expansion is assessed by palpation. Diaphragmatic excursion is assessed by percussion of the posterior chest. Breath sounds are assessed by auscultation

The nurse knows that auscultation of fine crackles would most likely be noticed in:

a. A healthy 5-year-old child.

b. A pregnant woman.

c. The immediate newborn period.

d. Association with a pneumothorax.

ANS: C

Fine crackles are commonly heard in the immediate newborn period as a result of the opening of the airways and a clearing of fluid. Persistent fine crackles would be observed 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?

a. In an obese patient

b. When part of the lung is obstructed or collapsed

c. When bulging of the intercostal spaces is present

d. When accessory muscles are used to augment respiratory effort

ANS: B

Unequal chest expansion occurs when part of the lung is obstructed or collapsed, as with pneumonia, or when guarding to avoid postoperative incisional pain.

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?

a. Airway obstruction

b. Emphysema

c. Pulmonary consolidation

d. Asthma

ANS: C

Pathological conditions that increase lung density, such as pulmonary consolidation, will enhance the transmission of voice sounds, such as bronchophony (see Table 19-3).

The nurse is reviewing the characteristics of breath sounds. Which statement about bronchovesicular breath sounds is true? Bronchovesicular breath sounds are:

a. Musical in quality.

b. Usually caused by a pathological condition.

c. Expected near the major airways.

d. Similar to bronchial sounds except shorter in duration.

ANS: C

Bronchovesicular breath sounds are heard over major bronchi where fewer alveoli are located posteriorly—between the scapulae, especially on the right; and anteriorly, around the upper sternum in the first and second intercostal spaces. The other responses are not correct

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?

a. Wheezes

b. Bronchial sounds

c. Bronchophony

d. Whispered pectoriloquy

ANS: A

Wheezes are caused by air squeezed or compressed through passageways narrowed almost to closure by collapsing, swelling, secretions, or tumours, such as with acute asthma or chronic emphysema

A patient has a long history of chronic obstructive pulmonary disease (COPD). During the assessment, the nurse will most likely observe which of these?

a. Unequal chest expansion

b. Increased tactile fremitus

c. Atrophied neck and trapezius muscles

d. Anteroposterior-to-transverse diameter ratio of 1:1

ANS: D

An anteroposterior-to-transverse diameter ratio of 1:1, or barrel chest, is observed in individuals with COPD because of hyperinflation of the lungs. The ribs are more horizontal, and the chest appears as if held in continuous inspiration. Neck muscles are hypertrophied from aiding in forced respiration. Chest expansion may be decreased but symmetrical. Decreased tactile fremitus occurs from decreased transmission of vibrations.

A 20-year-old tall, slim male 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 on the left, hyper-resonance on the left, and decreased breath sounds on the left. The nurse interprets that these assessment findings are consistent with:

a. Bronchitis.

b. Pneumothorax.

c. Acute pneumonia.

d. Asthmatic attack.

ANS: B

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 evident. Unequal chest expansion, decreased or absent tactile fremitus, tracheal deviation to the unaffected side, decreased chest expansion, hyper-resonant percussion tones, and decreased or absent breath sounds are found with the presence of pneumothorax. (See Table 19-8 for descriptions of the other conditions.)

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, the use of accessory neck muscles, prolonged expiration, intercostal retractions, decreased breath sounds, and expiratory wheezes. The nurse interprets that these assessment findings are consistent with:

a. Asthma.

b. Atelectasis.

c. Lobar pneumonia.

d. Heart failure.

ANS: A

Asthma is allergic hypersensitivity to certain inhaled particles that produces inflammation and a reaction of bronchospasm, which increases airway resistance, especially during expiration. An increased respiratory rate, the use of accessory muscles, a retraction of the intercostal muscles, prolonged expiration, decreased breath sounds, and expiratory wheezing are all characteristics of asthma. (See Table 19-8 for descriptions of the other conditions.)

The nurse is assessing the lungs of an 85-year-old patient who states having a decreased tolerance for activity. The nurse informs the patient that this results from some of the normal changes that occur in the respiratory system of the older adult:

a. Chest expansion increases with asymmetry.

b. Respiratory muscle strength increases to compensate for a decreased vital capacity.

c. A decrease in small airway closure occurs, leading to problems with atelectasis.

d. Lungs are less elastic and distensible, and this decreases their ability to collapse and recoil.

ANS: D

In older adults, the respiratory system is less efficient (decreased vital capacity, less surface area for gas exchange), and so they have less tolerance for activity. In the aging adult, the lungs are less elastic and distensible, which decreases their ability to collapse and recoil. Vital capacity is decreased, and a loss of intra-alveolar septa occurs, causing less surface area for gas exchange. The lung bases become less ventilated, and the older person is at risk for dyspnea with exertion beyond his or her usual workload

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?

a. “The diaphragm becomes fixed during pregnancy, making it difficult to take in a deep breath.”

b. “The increase in estrogen levels during pregnancy often causes a decrease in the diameter of the rib cage and makes it difficult to breathe.”

c. “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.”

d. “This increased awareness of the need to breathe is normal as the fetus grows because of the increased oxygen demand on the mother’s body, which results in an increased respiratory rate.”

ANS: C

During pregnancy, the woman may develop an increased awareness of the need to breathe. Some women may interpret this as dyspnea, although structurally nothing is wrong. Increases in estrogen relax the chest cage ligaments, causing an increase in the transverse diameter. Although the growing fetus increases the oxygen demand on the mother’s body, this increased demand is easily met by the increasing tidal volume (deeper breathing). Little change occurs in the respiratory rate.

A 35-year-old recent immigrant is being seen in the clinic for complaints of a cough that is associated with rust-coloured sputum, low-grade afternoon fevers, and night sweats for the past 2 months. The nurse’s preliminary analysis, based on this history, is that this patient may be suffering from:

a. Bronchitis.

b. Pneumonia.

c. Tuberculosis.

d. Pulmonary edema.

ANS: C

The appearance of sputum alone are not diagnostic, but some conditions have characteristic sputum production. Tuberculosis often produces rust-coloured sputum in addition to other symptoms of night sweats and low-grade afternoon fevers (see Table 19-8)

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 patient?

a. Shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, and ankle edema

b. Rasping cough, thick mucoid sputum, wheezing, and bronchitis

c. Productive cough, dyspnea, weight loss, anorexia, and tuberculosis

d. Fever, dry nonproductive cough, and diminished breath sounds

ANS: A

A person with heart failure often exhibits increased respiratory rate, shortness of breath on exertion, orthopnea, paroxysmal nocturnal dyspnea, nocturia, ankle edema, and pallor in light-skinned individuals. A patient with rasping cough, thick mucoid sputum, and wheezing may have bronchitis. Productive cough, dyspnea, weight loss, and dyspnea indicate tuberculosis; fever, dry nonproductive cough, and diminished breath sounds may indicate Pneumocystis jiroveci (P. carinii) pneumonia (see Table 19-8).

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 cough may indicate:

a. Pneumonia.

b. Postnasal drip or sinusitis.

c. Exposure to irritants at work.

d. Chronic bronchial irritation from smoking.

ANS: B

A cough that primarily occurs 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 illnesses, such as pneumonia, is continuous throughout the day

During a morning assessment, the nurse notices that the patient’s sputum is frothy and pink. Which condition could this finding indicate?

a. Croup

b. Tuberculosis

c. Viral infection

d. Pulmonary edema

ANS: D

The appearance of 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 cough, not sputum production. Tuberculosis may produce rust-coloured sputum. Viral infections may produce white or clear mucoid sputum.

To correctly auscultate the patient’s breath sounds, the nurse will:

a. Listen to at least one full respiration in each location.

b. Listen as the patient inhales and then go to the next site during exhalation.

c. Instruct the patient to breathe in and out rapidly while listening to the breath sounds.

d. If the patient is modest, listen to sounds over his or her clothing or hospital gown.

ANS: A

During auscultation of breath sounds with a stethoscope, listening to one full respiration in each location is important. During the examination, the nurse should monitor the breathing and offer times for the person to breathe normally to prevent possible dizziness

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?

a. Absent or decreased breath sounds

b. Productive cough with thin, frothy sputum

c. Chest pain that is worse on deep inspiration and dyspnea

d. Diffuse infiltrates with areas of dullness upon percussion

ANS: C

Findings for pulmonary embolism include chest pain that is worse on deep inspiration, dyspnea, apprehension, anxiety, restlessness, partial arterial pressure of oxygen (PaO2) less than 80 mm Hg, diaphoresis, hypotension, crackles, and wheezes.

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:

a. Tactile fremitus.

b. Crepitus.

c. Friction rub.

d. Adventitious sounds.

ANS: B

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, such 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:

a. Atelectatic crackles, which do not have a pathological cause.

b. Fine crackles and may be a sign of pneumonia.

c. Vesicular breath sounds.

d. Fine wheezes.

ANS: A

One type of adventitious sound, atelectatic crackles, does not have a pathological cause.

They are short, popping, crackling sounds that sound similar to fine crackles but do not last beyond a few breaths. When sections of alveoli are not fully aerated (as in people who are asleep or in older adults), they deflate slightly and accumulate secretions.

Crackles are heard when these sections are expanded by a few deep breaths.

Atelectatic crackles are heard only in the periphery, usually in dependent portions of the lungs, and disappear after the first few breaths or after a cough

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 respirations per minute. The nurse interprets this respiration pattern as which of the following?

a. Bradypnea

b. Cheyne-Stokes respirations

c. Hypoventilation

d. Chronic obstructive breathing

ANS: C

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 19-5 for descriptions of Cheyne-Stokes respirations and chronic obstructive breathing.)

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

a. Voice sounds are faint, muffled, and almost inaudible when the patient whispers “one, two, three” in a very soft voice.

b. As the patient repeatedly says “ninety-nine,” the examiner clearly hears the words “ninety-nine.”

c. When the patient speaks in a normal voice, the examiner can hear a sound but cannot exactly distinguish what is being said.

d. As the patient says a long “ee-ee-ee” sound, the examiner also hears a long “ee-ee-ee” sound.

e. As the patient says a long “ee-ee-ee” sound, the examiner hears a long “aaaaaa” sound.

ANS: A, C, D

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

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.)

a. Decreased breath sounds with extended expirations

b. Respirations 10 breaths/minute

c. Diaphragmatic excursion 5 cm equal bilaterally

d. Heart sounds are muffled

e. Crackles auscultated throughout lung fields

f. Costal angle greater than 90 degrees

ANS: A, D, F

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

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.)

a. Respirations regular and easy

b. Crackles upon auscultation of lungs

c. Muscles between ribs pull in during inspiration

d. Very short of breath

e. Blood pressure 70/50 mm Hg

f. Apical heart rate 60 beats per minut

ANS: B, C, D, E

(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 PaO2, blood gases show respiratory alkalosis, radiographs show diffuse pulmonary infiltrates, a late sign is cyanosis.

Palpation: Hypotension.

Auscultation: Tachycardia.

Adventitious sounds: Crackles, rhonchi