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Foundations
Exam 3
| Question | Answer |
|---|---|
| Softly whispering “one-two-three” while the nurse auscultates the chest is a correct instruction for the | whispered pectoriloquy test. |
| Having the client say “ninety-nine” is used to test | bronchophony. |
| Saying the letter “e” is used to test | egophony. |
| Having the client cough is useful if an abnormal sound is heard during auscultation to determine if | coughing clears the lungs. |
| The thin double-layered serous membrane that lines the chest cavity is termed | parietal pleura. |
| The nurse assesses an adult client’s thoracic area and observes a markedly sunken sternum and adjacent cartilages. The nurse should document the client’s | pectus excavatum. |
| a markedly sunken sternum and adjacent cartilages (often referred to as funnel chest). It is a congenital malformation that seldom causes symptoms other than self-consciousness | Pectus excavatum |
| During the lung assessment for a client with pneumonia, the nurse auscultates low-pitched bubbling, moist sounds that persists from early inspiration to early expiration. How should the nurse document these sounds? | Coarse crackles |
| Low-pitched bubbling, moist sounds that persists from early inspiration to early expiration and sounds like softly separating Velcro should be documented as | coarse crackles. |
| low-pitched, dry, grating sound which is superficial and occurs during both inspiration and expiration. | Pleural friction rub |
| These sounds are produced when inhaled air comes into contact with secretions in the large bronchi and trachea. | coarse crackles. |
| are low pitched snoring or moaning sounds that may be heard primarily during expiration but may be heard throughout the respiratory cycle. | Sonorous wheezes |
| are high-pitched musical sounds heard primarily during expiration but may also be heard on inspiration. | Sibilant wheezes |
| is marked by a chronic, productive cough that results from excess mucus production. | Bronchitis |
| is uncommon in younger clients. It would be simplistic to differentiate cardiac from respiratory chest pain based on severity alone. Similarly, it is inaccurate to characterize all loud percussion sounds as pathological. | Hemoptysis |
| decreased rate, decreased depth, and irregular pattern of respiration is. | Hypoventilation |
| A client with regular pattern characterized by alternating periods of deep, rapid breathing followed by periods of apnea has | Cheyne-Stokes respiration. |
| A client with irregular pattern characterized by varying depth and rate of respirations followed by periods of apnea has | Biot's respiration. |
| A client may have a regular respiration rate of less than 10/min. with | bradypnea |
| causes shortness of breath and a nocturnal cough. It is often associated with a history of allergies and can be exacerbated by exercise or irritants such as smoke in a bar. On auscultation there can be normal to decreased air movement. | Asthma |
| heard on expiration & sometimes inspiration. duration in expiration usually correlates with severity of illness, so it is important to document length. In severe asthma, may not be heard due to the lack of air movement. clients may have more after treatme | Wheezing |
| percussion over the scapula elicits | flat tones. |
| is heard over the normal lung tissue. | Resonance |
| is heard when fluid or solid tissue replaces air in the lung. | Dullness |
| is elicited in cases of trapped air, such as in emphysema or pneumothorax. | Hyperresonance |
Created by:
klmd3014