Assessing Thorax & Lungs

Under normal circumstances, what is the strongest stimulus to breathe?

• hypercapnia

• hypoxemia

• consolidation

• dyspnea

The nurse is preparing to auscultate a client's lungs after completing thoracic inspection, palpation, and percussion. How should the nurse best prepare for this assessment technique?

• Keep the client's shirt or gown in place to maintain privacy.

• Begin with the bell of the stethoscope on the client's anterior chest.

• Tell the client that you will be asking them to breathe as quickly and deeply as possible.

• Place the diaphragm on the client's posterior chest wall.

The nurse's auscultation of a client's lung fields reveals the presence of a wheeze. The nurse should recognize that this adventitious sound results from what pathophysiologic process?

• Air leaking from the alveoli into the pleural space

• Air being diverted from the trachea to the bronchi

• Air increasing in turbulence in a wide passage

• Air passing through constricted passageways

The nurse is assessing a client's respiratory rate and rhythm during the beginning of a shift. The client's rate is 29 breaths/min. How should the nurse respond to this assessment finding?

• Ask the client if she has recently exerted herself.

• Report the finding to the client's primary care provider.

• Ask the client if she has smoked recently.

• Palpate the client's anterior and posterior thorax.

While assessing the health of a client's respiratory system, the nurse is palpating for fremitus. What instruction should the nurse provide to the client during this component of assessment?

• “When I say so, please exhale forcefully and hold the breath.”

• “Say the letter “e” and keep saying it until I tell you to stop.”

• “Breathe in as deeply as you can and hold your breath until I say to stop.”

• “Please say the number “ninety-nine” for me.”

The nurse is performing a respiratory assessment of a client who is receiving palliative care only due to severe, uncompensated heart failure. What type of respiratory pattern should the nurse anticipate?

• Biot

• Cheyne–Stoke

• Bradypnea

• Kussmaul

The nurse assesses chest expansion in a 30-year-old man and finds it to be 8 cm. How would the nurse document this finding?

• Limited expansion

• Normal expansion

• hypoexpansion

• Hyperexpansion

The nurse is assessing a 69-year-old woman's risks for lung disease. The woman states, “It shouldn't be a problem for me. My husband smokes quite heavily but I've been a lifelong nonsmoker.” The nurse should recognize the need to teach the client about what topic?

• Strategies for making her husband quit smoking

• Genetic causes of lung cancer

• Age-related changes to respiratory function

• Health risks of secondhand smoke

The nurse is assessing a 79-year-old client's posterior thorax during a focused respiratory assessment. The nurse should attribute what assessment finding to age-related changes?

• Slight kyphosis

• Inaudible posterior lung sounds

• Audible wheeze

• Asymmetrical chest expansion

A nursing instructor is discussing cultural variations in the size of the thorax and impact on lung capacity. Which group would the instructor identify as typically having a larger thorax?

• African Americans

• Native Americans

• Asian Americans

• Caucasians