ASSESSING THORAX AND LUNGS

A.
1. The clavicles extend from the acromion of the scapula to the part of the sternum termed
- Manubrium

2. A body ridge located at the point where the manubrium articulates with the body of the sternum
is termed
- Sternal notch

3. The spinous process termed the vertebra prominens is in which cervical vertebra?
- C7

4. The apex of each lung is located at the

- Area slightly above the clavicle

5. The thin double-layered serous membrane that lines the chest cavity is termed
- Parietal pleura

6. The lining of the trachea and bronchi, which serves to remove dust, foreign bodies, and
bacteria, is termed
- Cilia

7. Under normal circumstances, the strongest stimulus to breath is

- Hypercapnia

8. 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

9. The nurse has assessed the respiratory pattern of an adult client. The nurse determines that
the client is exhibiting Kussmaul respirations with hyperventilation. The nurse should contact
the client’s physician because this type of respiratory pattern usually indicates
- Diabetic Ketoacidosis

10. The client has been admitted through the emergency department with chronic bronchitis, has
elevated CO2 levels, and has been placed on O2. What priority assessment would the nurse
include?
- Evaluate changes in respiratory pattern and rate
B.
1. Promotes the strongest stimulus
- An increase in carbon dioxide in the blood

2. Orthopnea
- Difficulty breathing when lying supine

3. Crepitus
- A “crackling” sensation

4. Pectus excavatum
- Pectus excavatum

5. Pectus carinatum
- Forward protrusion of the sternum

6. Pleural friction rub

- Low-pitched, dry, grating sound

7. Wheeze (Sibilant)
- High-pitched, short, popping sounds

8. Wheeze (sonorous)
- Low-pitched snoring or moaning sounds

9. Crackles (Fine)
- High-pitched, short, popping sounds

10. Crackles (Course)

- Low-pitched, bubbling moist sounds
1. While assessing an adult client, the client tells the nurse that she "has had difficulty catching
her breath since yesterday." The nurse should assess the client further for signs and symptoms
of
- Infection

2. An adult client visits the clinic and tells the nurse that he has been "spitting up rust-colored
sputum.” The nurse should refer the client to the physician for possible
- Tuberculosis

3. The nurse is planning a presentation to a group of high school students on the topic of lung
cancer. Which of the following should the nurse plan to include in the presentation?
- Studies have indicated that there is a genetic component in the development of lung cancer

4. While assessing an adult client, the nurse observes decreased chest expansion at the bases of
the client's lungs. The nurse should refer the client to a physician for possible
- Chronic obstructive pulmonary disease

5. The nurse is planning to percuss the chest of an adult male client for diaphragmatic excursion.
The nurse should begin the assessment by
- Asking the client to exhale forcefully and hold his breath

6. The nurse is preparing to auscultate the posterior thorax of an adult female client. Th e nurse
should
- Ask the client to breathe deeply through her mouth

7. While assessing the thoracic area of an adult client, the nurse plans to auscultate for voice
sounds. To assess bronchophony, the nurse should ask the client to
- Repeat the phrase “ninety-nine”

8. The nurse assesses an adult client and observes that the client's breath ing pattern is very
labored and noisy, with occasional coughing. The nurse should refer the client to a physician for
possible
- Chronic bronchitis

9. While assessing an adult client's lungs during the postoperative period, the nurse detects
coarse crackle. The nurse should refer the client to a physician for possible
- Pneumonia

10. The nurse assesses an adult client's breath sounds and hears sonorous wheezes, primarily
during the client's expiration. The nurse should refer the client to a physician for possible
- Bronchitis
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