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Which of these statements is true regarding the vertebra prominens? The vertebra
prominens is: - ANSWER The spinous process of C7.
When performing a respiratory assessment on a patient, the nurse notices a costal angle of
approximately 90 degrees. This characteristic is: - ANSWER A normal finding in a healthy
adult.
When assessing a patients lungs, the nurse recalls that the left lung: - ANSWER Consists
of two lobes.
Which statement about the apices of the lungs is true? The apices of the lungs: -
ANSWER Extend 3 to 4 cm above the inner third of the clavicles.
During an examination of the anterior thorax, the nurse is aware that the trachea bifurcates
anteriorly at the: - ANSWER Sternal angle
During an assessment, the nurse knows that expected assessment findings in the normal
adult lung include the presence of: - ANSWER Muffled voice sounds and symmetric
tactile fremitus.
The primary muscles of respiration include the: - ANSWER Diaphragm and intercostals.
A 65-year-old patient with a history of heart failure comes to the clinic with complaints of
being awakened from sleep with shortness of breath. Which action by the nurse is most
appropriate? - ANSWER Assessing for other signs and symptoms of paroxysmal nocturnal
dyspnea
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,When assessing tactile fremitus, the nurse recalls that it is normal to feel tactile fremitus
most intensely over which location? - ANSWER Between the scapulae
The nurse is reviewing the technique of palpating for tactile fremitus with a new graduate.
Which statement by the graduate nurse reflects a correct understanding of tactile fremitus?
Tactile fremitus: - ANSWER Is caused by sounds generated from the larynx.
Tactile Fremitus is what? - ANSWER Palpable vibration
The nurse is observing the auscultation technique of another nurse. The correct method to
use when progressing from one auscultatory site on the thorax to another is _______
comparison. - ANSWER Side-to-side
During percussion, the nurse knows that a dull percussion note elicited over a lung lobe
most likely results from: - ANSWER Increased density of lung tissue.
When auscultating the lungs of an adult patient, the nurse notes that low-pitched, soft
breath sounds are heard over the posterior lower lobes, with inspiration being longer than
expiration. The nurse interprets that these sounds are: - ANSWER Vesicular breath
sounds and normal in that location.
The nurse is percussing over the lungs of a patient with pneumonia. The nurse knows that
percussion over an area of atelectasis in the lungs will reveal: - ANSWER Dullness
The nurse is auscultating the chest in an adult. Which technique is correct? - ANSWER
Firmly holding the diaphragm of the stethoscope against the chest
During auscultation of the lungs, the nurse expects decreased breath sounds to be heard in
which situation? - ANSWER When the bronchial tree is obstructed
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, The nurse knows that a normal finding when assessing the respiratory system of an older
adult is: - ANSWER Decreased mobility of the thorax.
When assessing the respiratory system of a 4-year-old child, which of these findings would
the nurse expect? - ANSWER Presence of bronchovesicular breath sounds in the
peripheral lung fields
A mother brings her 3-month-old infant to the clinic for evaluation of a cold. She tells the
nurse that he has had a runny nose for a week. When performing the physical assessment,
the nurse notes that the child has nasal flaring and sternal and intercostal retractions. The
nurses next action should be to: - ANSWER Recognize that these are serious signs, and
contact the physician.
When inspecting the anterior chest of an adult, the nurse should include which assessment?
- ANSWER Shape and configuration of the chest wall
The nurse knows that auscultation of fine crackles would most likely be noticed in: -
ANSWER The immediate newborn period.
During an assessment of an adult, the nurse has noted unequal chest expansion and
recognizes that this occurs in which situation? - ANSWER When part of the lung is
obstructed or collapsed
During auscultation of the lungs of an adult patient, the nurse notices the presence of
bronchophony. The nurse should assess for signs of which condition? - ANSWER
Pulmonary consolidation
The nurse is reviewing the characteristics of breath sounds. Which statement about
bronchovesicular breath sounds is true? Bronchovesicular breath sounds are: - ANSWER
Expected near the major airways.
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