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A client with myocardial infarction suddenly
becomes tachycardic, shows signs of air hunger,
and begins coughing frothy, pink-tinged sputum.
2
Which finding would the nurse anticipate when
auscultating the client's breath sounds?
Frothy, pink sputum+ dyspnea, air hunger c/w pulmonary
1. Stridor
edema. Would expect crackles
2. Crackles
3. Scattered rhonchi
4. Diminished breath sounds
The nurse is assessing the respiratory status of a client
who has suttered a fractured rib. The nurse
should expect to note which finding?
1. Slow, deep respirations 4
2. Rapid, deep respirations
3. Paradoxical respirations
4. Pain, especially with inspiration
A client with a chest injury has suttered flail chest.
The nurse assesses the client for which most distinctive
sign of flail chest?
1. Cyanosis 3
2. Hypotension
3. Paradoxical chest movement
4. Dyspnea, especially on exhalation
A client with a diagnosis of asthma is admitted to
the hospital with respiratory distress. Which type 3
of adventitious lung sounds should the nurse
expect to hear when performing a respiratory Asthma is a respiratory disorder characterized by
assessment on this client? recurring episodes of dyspnea, constriction of the
1. Stridor bronchi, and wheezing
2. Crackles
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3. Wheezes
4. Diminished
Which action by a nurse demonstrates proper technique
for assessment of chest expansion?
Use the ball of both hands to feel for vibrations in a C
symmetrical pattern across the posterior chest
Beginning at the scapular line, percuss the intercostal The correct technique for assessment of chest expansion is
spaces along both sides of the posterior chest for the examiner to place the hands on the posterior chest
Place both hands on the posterior chest at T9, press wall with thumbs at the level of T9 or T10 and pressing
thumbs together, and then ask client to take a deep together a small skin fold. Ask the client to take a deep
breath breath and observe the movement of the thumbs.
Place the stethoscope on the posterior chest wall, ask the
client to take a deep breath, and observe chest rise and
fall
The apex of each lung is located at the
level of the diaphragm.
B
area slightly above the clavicle.
level of the sixth rib.
left oblique fissure.
Which action by a nurse demonstrates the proper se-
quence for auscultation of the lung fields?
A
Listen at each site for at least one complete respiratory
cycle The client is instructed to breathe deeply though the
Move from anterior to posterior on the same side mouth for each area as the nurse listens through inspi-
Instruct the client to breathe in and out rapidly through ration and expiration.
the mouth
Use the diaphragm then the bell in each location