Chapter 19 NCLEX Quesrions

The vertebra prominens is:

• The spinous process of C7

• Usually nonpalpable in most individuals

• Opposite the interior border of the scapula

• Located next to the manubrium of the sternum

A costal angle of approximately 90 degrees is:

• Observed in patients with kyphosis

• Indicative of pectus excavatum

• A normal finding in a healthy adult

• An expected finding in a patient with a barrel chest

The left lung:

• Consists of two lobes

• Is divided by the horizontal fissure

• Primarily consists of an upper lobe on the posterior chest

• Is shorter than the right lung because of the underlying stomach

The apices of the lungs:

• Are at the level of the second rib anteriorly

• Extend 3 to 4 cm above the inner third of the clavicles

• Are located at the sixth rib anteriorly and the eighth rib laterally

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

The trachea bifurcates anteriorly at the:

• Costal angle

• Sternal angle

• Xiphoid process

• Suprasternal notch

The normal adult lung include the presence of:

• Adventitious sounds and limited chest expansion

• Increased tactile fremitus and dull percussion tones

• Muffled voice sounds and symmetric tactile fremitus

• Absent voice sounds and hyperresonant percussion tones

The primary muscles of respiration include the:

• Diaphragm and intercostals

• Sternomastoid and scaleni

• Trapezii and rectus abdominis

• External obliques and pectoralis major

Which action by the nurse is most appropriate for an older patient with a history of heart failure who complains of shortness of breath at night?

• Obtaining a detailed health history of the patient’s allergies and a history of asthma

• Telling the patient to sleep on his or her right side to facilitate ease of respirations

• Assessing for other signs and symptoms of paroxysmal nocturnal dyspnea ***

• Assuring the patient that paroxysmal nocturnal dyspnea is normal and will probably resolve within the next week

It is normal to feel tactile fremitus most intensely over which location?

• Between the scapulae

• Third intercostal space, MCL

• Fifth intercostal space, midaxillary line (MAL)

• Over the lower lobes, posterior side

Tactile fremitus:

• Is caused by moisture in the alveoli

• Indicates that air is present in the subcutaneous tissues

• Is caused by sounds generated from the larynx

• Reflects the blood flow through the pulmonary arteries