MARYVILLE EXAM 2 NURS 612 QUESTIONS AND ANSWERS
inspect the chest - (answer)without clothes on; 1st assess shape and size; 2nd check for symmetry; 3rd
thoracic landmarks; 4th color of skin; 5th check for supernumerary nipples; 6th superficial venous
patterns; and 7th observe for rib prominence
thoracic landmarks - (answer)midline trachea, costal angle, angle of ribs, intercostal spaces, suprasternal
notch
symmetry of chest - (answer)thoracic expansion at costal angle, w/o use of accessory muscles
hx questions for cc of resp issue - (answer)What is the nature of your cough?; Do you produce any
sputum?; Is your cough related to activity?; What position are you most comfortable in?; How many
pillows do you sleep with at night?; Is your SOB related to activity?
normal respirations - (answer)rate between 12 to 20/min; ratio of resp to heart beats= 1:4; pt should
breathe easily, regularly w/o apparent distress; pattern should be even, not too shallow or too deep
hypopnea - (answer)term for abnormally shallow respirations
tachypnea - (answer)term for resp rate greater than 20, but consistent and may occur during
hyperventilation; often a symptom of pain
bradypnea - (answer)term for resp rate less than 12; may indicate neurologic or electrolyte
disturbances, infection, or conscious response to protect against the pain of pleurisy or other irritative
pneumonia. Can also be 2/2 level of cardio fitness
hyperventilation - (answer)term for fast and deep, heavy respirations, can be caused by exercise,
anxiety, and CNS and metabolic diseases
hyperpnea - (answer)term for abnormally deep respirations
, MARYVILLE EXAM 2 NURS 612 QUESTIONS AND ANSWERS
kussmaul respirations - (answer)deep and mostly rapid respirations, used to describe resp effort of
metabolic acidosis
cheyne stokes respirations - (answer)regular breathing with intervals of apnea by crescendo
decrescendo breathing; can be seen in sleeping pts, but mostly pts who are very ill, esp with brain
damage
biot respirations - (answer)irregular breathing that varies in depth and is interrupted irregularly by
intervals of apnea; associated with severe and persistent increased intracranial pressure, resp
compromise from drug poisoning, or brain damage at the medulla and generally equals poor prognosis
peripheral areas related to respiratory assessment - (answer)observe the lips and nails for cyanosis or
pallor; lips for pursing; fingers for clubbing; and alae nasi for flaring
pleural friction rub - (answer)dry, rubbing, or grating sound; palpable, coarse, grating vibration; usually
on inspiration; caused by inflammation of the pleural surfaces; think feel of leather rubbing on leather
thoracic expansion - (answer)stand behind patient and place thumbs along spinal process at level of
10th rib, with palms lightly in contact with the posterolateral surfaces; watch the thumbs during quiet
and deep breathing; loss of symmetry = problem on either 1 or both sides.
crepitus - (answer)crackly/crinkly sensation that can be palpated and heard, a gentle bubbly feeling;
indicates air in the subcutaneous tissue from a rupture somewhere in the resp system, or infection with
gas producing organism
palpating the chest and trachea - (answer)palpate the throracic muscles and skeleton; feeling for
pulsations, areas of tenderness, bulges, depressions, masses, and unusual movement
tactile fremitus - (answer)palpable vibration of the chest wall that results from speech or other
verbalizations. best felt posteriorly and laterally at the level of the bifurcation of the bronchi; have
patient say "99" while you palpate with palmer surface of fingers or ulner aspect of the hand; use firm,
light touch
inspect the chest - (answer)without clothes on; 1st assess shape and size; 2nd check for symmetry; 3rd
thoracic landmarks; 4th color of skin; 5th check for supernumerary nipples; 6th superficial venous
patterns; and 7th observe for rib prominence
thoracic landmarks - (answer)midline trachea, costal angle, angle of ribs, intercostal spaces, suprasternal
notch
symmetry of chest - (answer)thoracic expansion at costal angle, w/o use of accessory muscles
hx questions for cc of resp issue - (answer)What is the nature of your cough?; Do you produce any
sputum?; Is your cough related to activity?; What position are you most comfortable in?; How many
pillows do you sleep with at night?; Is your SOB related to activity?
normal respirations - (answer)rate between 12 to 20/min; ratio of resp to heart beats= 1:4; pt should
breathe easily, regularly w/o apparent distress; pattern should be even, not too shallow or too deep
hypopnea - (answer)term for abnormally shallow respirations
tachypnea - (answer)term for resp rate greater than 20, but consistent and may occur during
hyperventilation; often a symptom of pain
bradypnea - (answer)term for resp rate less than 12; may indicate neurologic or electrolyte
disturbances, infection, or conscious response to protect against the pain of pleurisy or other irritative
pneumonia. Can also be 2/2 level of cardio fitness
hyperventilation - (answer)term for fast and deep, heavy respirations, can be caused by exercise,
anxiety, and CNS and metabolic diseases
hyperpnea - (answer)term for abnormally deep respirations
, MARYVILLE EXAM 2 NURS 612 QUESTIONS AND ANSWERS
kussmaul respirations - (answer)deep and mostly rapid respirations, used to describe resp effort of
metabolic acidosis
cheyne stokes respirations - (answer)regular breathing with intervals of apnea by crescendo
decrescendo breathing; can be seen in sleeping pts, but mostly pts who are very ill, esp with brain
damage
biot respirations - (answer)irregular breathing that varies in depth and is interrupted irregularly by
intervals of apnea; associated with severe and persistent increased intracranial pressure, resp
compromise from drug poisoning, or brain damage at the medulla and generally equals poor prognosis
peripheral areas related to respiratory assessment - (answer)observe the lips and nails for cyanosis or
pallor; lips for pursing; fingers for clubbing; and alae nasi for flaring
pleural friction rub - (answer)dry, rubbing, or grating sound; palpable, coarse, grating vibration; usually
on inspiration; caused by inflammation of the pleural surfaces; think feel of leather rubbing on leather
thoracic expansion - (answer)stand behind patient and place thumbs along spinal process at level of
10th rib, with palms lightly in contact with the posterolateral surfaces; watch the thumbs during quiet
and deep breathing; loss of symmetry = problem on either 1 or both sides.
crepitus - (answer)crackly/crinkly sensation that can be palpated and heard, a gentle bubbly feeling;
indicates air in the subcutaneous tissue from a rupture somewhere in the resp system, or infection with
gas producing organism
palpating the chest and trachea - (answer)palpate the throracic muscles and skeleton; feeling for
pulsations, areas of tenderness, bulges, depressions, masses, and unusual movement
tactile fremitus - (answer)palpable vibration of the chest wall that results from speech or other
verbalizations. best felt posteriorly and laterally at the level of the bifurcation of the bronchi; have
patient say "99" while you palpate with palmer surface of fingers or ulner aspect of the hand; use firm,
light touch
