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NURS 6023 - Advanced Assessment and Diagnostic Evaluation Exam 2 | Study guide and test (Answered) | Latest Summer 2025-26 Updated.

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NURS 6023 - Advanced Assessment and Diagnostic Evaluation Exam 2 | Study guide and test (Answered) | Latest Summer 2025-26 Updated.

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BATES CHAPTER 15

 Intercostal space number = rib number above it
 Sternal angle (Angle of Louis) - horizontal bony ridge where manubrium joins body of sternum
o Directly adjacent to 2nd rib and costal cartilage
 2nd intercostal space for needle insertion to decompress tension pneumothorax
 Intercostal space between 4th and 5th ribs = chest tube insertion
 Level of 4th rib = lower margin of well-placed ET tube
 Costal cartilage of 1-7 ribs articulate with sternum
 Cartilage of 8-10 articulate with costal cartilage above them
 11 and 12 rib have no anterior attachment = “floating rib”
 Posteriorly, 12th rib is starting point for counting ribs and intercostal spaces
o Inferior scapula tip usually at 7th rib or intercostal space
o When neck is flexed forward, most protruding process usually C7 vertebra, ribs
coincide with thoracic vertebrae
 Intercostal space between 7 and 8 = thoracentesis needle immediately superior to 8th rib
 Midsternal line – along sternum
 Midclavicular line – clavicular midpoint
 Anterior axillary line – anterior axillary fold
 Midaxillary line – axilla apex
 Posterior axillary line – posterior axillary fold
 Scapular line – inferior angle of scapula
 Vertebral line – overlies thoracic spinous processes
 “Triangle of Safety” – in midaxillary line formed by lateral border pectoralis major anteriorly,
lateral border latissimus dorsi posteriorly, nipple line (4th and 5th intercostal space) inferiorly
– “safe position” for chest tube insertion
 Apex of each lung about 2-4 cm above inner 1/3 of clavicle
 Anterior lung lower border crosses 6th rib at midclavicular line and 8th rib at midaxillary line
 Posterior lung border at T10
 Inspiration descends d/t constriction and descension of diaphragm
 Oblique (major) fissure – divides lung in half
o T3 obliquely down and around chest to 6th rib at midclavicular line
 Horizontal (minor) fissure – further divides R lung
o Runs anteriorly close to 4th rib and meets oblique fissure in midaxillary line near 5th
rib
 R lung – upper, middle, lower lobe
 L lung – upper and lower lobe
 Supraclavicular – above clavicles
 Infraclavicular – below clavicles
 Interscapular – between scapulae
 Infrascapular – below scapulae
 Apex of lung – uppermost portion
 Base of lung – lowermost portion
 Trachea bifurcates into mainstem bronchi at sternal angle and T4
o R main bronchus wider, shorter, more vertical than L main and directly enters lung
hilum
 Aspiration PNA more common in R middle and lower lobes

, o L main bronchus extends inferolaterally from below aortic arch and anterior to
esophagus and thoracic aorta and then enters lung hilum
 Each main bronchus divides into lobar then segmental bronchi and bronchioles and
terminated into sac-like alveoli where gas exchange occurs
 Two continuous pleural surfaces, or serous membranes, separate lungs from chest wall
o Visceral pleura covers outer surface of lung
o Parietal pleura lines pleural cavity along inner rib cage and upper diaphragm surface
o Pleural space between visceral and parietal contains serous fluid
 Pleural effusion - accumulation of pleural fluid
 Parietal pleura inflammation causes pleuritic pain
 Diaphragm – primary muscle of inspiration
o Inspiration – contraction – descends
o Scalenes – run from cervical vertebrae to 1st 2 ribs
o Parasternals – parasternal intercostal muscles cross obliquely from sternum to ribs
o Intrathoracic pressure decreases as thorax expands drawing air through
tracheobronchial tree into alveoli
o Expiration – relaxes – ascends
 Abd muscles assist
o Accessory muscles – SCM and scalenes
 History
o Symptoms that warrant medical interventions
 Inability to speak in full sentences, use of accessory muscles, cyanosis, evidence
of low O2 sat, pulsus paradoxicus
o Thorough past medical hx, complete medical and allergy list
o Social hx – tobacco and recreational drugs, occupational and environmental exposures,
travel hx
 Dyspnea (shortness of breath) - painless but uncomfortable awareness of breathing that’s
inappropriate to level of exertion
o Anxious patient present different
 Difficulty taking deep breath, smothering sensation with ability to get enough
air, parathesis (sensation fo tingling or “pins and needles” around lips and
extremities)
 Wheezes – musical respiratory sound may be audible to pt and others
 Cough – reflex response to stimuli irritates receptors
o Acute = < 3 week
o Subacute = 3-8 week
o Chronic = > 8 week
o Dry/productive, volume of sputum with color consistency odor
 Mucoid – translucent white or gray in viral infection of cystic fibrosis
 Purulent – yellow or green in bacterial
 Foul smelling – anaerobic lung abscess
 Thick and tenacious – cystic fibrosis
o Associated symptoms often lead to cause
 Hemoptysis – blood coughed up from lower respiratory tract
o Vary from blood streaked to frank blood
o Confirm source – lungs, pharynx, nose, mouth, GI tract
 Chest pain – lung tissues have no pain receptors

, Physical exam should begin during interview by observing pt speak
o Inability to speak full sentences without stopping = increased respiratory drive or
impairment of ventilation with reduced vital capacity
o Increased work of breathing (supraclavicular retractions, use of accessory muscles of
ventilation, tripod position) = increased airway resistance or stiff lung/chest wall
 Signs of respiratory distress
o Tachypnea – > 25 breaths/min
o Cyanosis or pallor
o Audible breathing sounds
o Accessory muscle use
 Posterior chest
o Arms folded across chest with hands on shoulders – allows increased access to lung
fields
o Note shape and how chest moves
o Focus palpation on tender or bruising areas
o Sinus tracts – blind inflammatory tube-like structures opening onto skin
o Test chest expansion – lung excursion
o Tactile fremitus – palpable vibrations transmitted through bronchopulmonary tree to
chest wall as speaking “ninety-nine” or “one-one-one"
o Percussion helps establish underlying tissues filled with air, fluid, or consolidation
BOX 15-3
 Pleximeter finger – stable middle finger
 Plexor finger – striking middle finger
 Flat, dull, resonant, hyper resonant, tympanic
 Diaphragmatic excursion
o Auscultation – assessing airflow BOX 15-4
 Cough once or twice to clear mild atelectasis or mucus
 Diaphragm of stethoscope with ladder pattern
 Silent gap suggests bronchial breath sound
 Vesicular – soft and light pitched without pause
 Bronchovesicular – inspiration and expiration equal length separated by slight
interval
 Bronchial – louder, harsher, and higher pitch with short silent gap, expiration >
inspiration
 Tracheal – loud harsh sound
 Adventitious lung sounds – added sounds superimposed on usual breath sound
 Crackles/rales
 Wheezes
 Rhonchi
 Silent chest = minimal air movement = CLINICAL EMERGENCY
 Pleural friction rub – coarse grating biphasic usually on exp
 Egophony - “ee” sounds like “a” with nasal quality
 Bronchophony - “ninety-nine”, not muffled, distinct louder voice
 Pectoriloquy – whisper “ninety-nine” or “one-two-three", louder clearer whisper
sound
 Should be faint and indistinct if heard at all
 Anterior chest – same as posterior

,  2002 American Thoracic Society – 6-minute walk test to predict clinical outcome of COPD
patient
o Tests pulmonary function
o Require 100 ft hallway
o Measures distance patient can quickly walk on flat hard surface in 6 minutes
 Forces expiratory time
o Slowed in obstructive pulmonary disease
o Take deep breath in then out as quickly and completely as possible with mouth open
o Listen over trachea and time audible expiration
o Try to get 3 consistent reading with short rest between
 Fractured rib – local pain and tenderness in 1 or more ribs
o Compress chest on AP plane (sternum and thoracic spine) to distinguish fracture from
soft tissue injury
o “This painful? Where?”
 Lung cancer
o 2nd most frequently diagnoses cancer in US and leading cause of cancer death in men
and women
o Risk factors – cigarette smoking, radon, familial risk
o Longer smoking hx and greater amount smoked associated with higher risk
o Only 16% diagnosed at early stage
o USPSTF grade B – low-dose-computed tomography (LDCT) lung cancer screening
 Annual screening recommended for current smoker (or quit within last 15 years)
if smoked average 1 pack for 30 yr and age 55-80
 Counsel smoking cessation and offer smoking cessation interventions
 Latent tuberculosis
o Tuberculin skin test (TST)
 Placement of purified protein derivative and 48-72 hr interpretation
 Measured in mm of induration – palpable raised hardened area of swelling
 Presence of induration = positive test
o Interferon-gamma release assay (IGRA) blood test
 Single venous blood draw and lab processing within 8-30 hour
o USPSTF grade B rec for screening latent TB in asymptomatic adult at increased risk for
TB
o USPSTF – moderately beneficial to treat latent TB in preventing progression to active
disease
 Primary harm = hepatotoxicity
 Obstructive sleep apnea (OSA) – repeated episodes of upper airway collapse during rapid eye
movement (REM) sleep leading to hypoxemia and disrupted sleep
o Definitive diagnosis with polysomnography in sleep lab
 Measures brainwaves, air flow, respiratory effort, oxygenation, and heart rhythm
 Severity based on hourly number of apnea episodes (breathing cessation ≥ 10
seconds) and hypopnea (breathing reduction ≥ 10 seconds accompanied by O2
desaturation or sleep arousal)
o Primary treatment – positive airway pressure
 Continuous (CPAP)
 Bilevel (BiPAP)
 Auto titrating (APAP)

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