Which of these statements is true regarding the vertebra prominens? The vertebra prominens
is:
a. The spinous process of C7.
b. Usually nonpalpable in most individuals.
c. Opposite the interior border of the scapula.
d. Located next to the manubrium of the sternum.
A
When performing a respiratory assessment on a patient, the nurse notices a costal angle of
approximately 90 degrees. This characteristic is:
a. Observed in patients with kyphosis.
b. Indicative of pectus excavatum.
c. A normal finding in a healthy adult.
d. An expected finding in a patient with a barrel chest.
C
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Brainpower
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When assessing a patients lungs, the nurse recalls that the left lung:
a. Consists of two lobes.
b. Is divided by the horizontal fissure.
c. Primarily consists of an upper lobe on the posterior chest.
d. Is shorter than the right lung because of the underlying stomach.
A
,Which statement about the apices of the lungs istrue? The apices of the lungs:
a. Are at the level of the second rib anteriorly.
b. Extend 3 to 4 cm above the inner third of the clavicles.
c. Are located at the sixth rib anteriorly and the eighth rib laterally.
d. Rest on the diaphragm at the fifth intercostal space in the midclavicular line (MCL).
B
During an examination of the anterior thorax, the nurse is aware that the trachea bifurcates
anteriorly at the:
a. Costal angle.
b. Sternal angle.
c. Xiphoid process.
d. Suprasternal notch.
B
During an assessment, the nurse knows that expected assessment findings in the normal adult
lung include the presence of:
a. Adventitious sounds and limited chest expansion.
b. Increased tactile fremitus and dull percussion tones.
c. Muffled voice sounds and symmetric tactile fremitus.
d. Absent voice sounds and hyperresonant percussion tones.
C
The primary muscles of respiration include the:
a. Diaphragm and intercostals.
b. Sternomastoids and scaleni.
c. Trapezii and rectus abdominis.
d. External obliques and pectoralis major.
A
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?
a. Obtaining a detailed health history of the patients allergies and a history of asthma
b. Telling the patient to sleep on his or her right side to facilitate ease of respirations
c. Assessing for other signs and symptoms of paroxysmal nocturnal dyspnea
,d. Assuring the patient that paroxysmal nocturnal dyspnea is normal and will probably resolve
within
the next week
C
When assessing tactile fremitus, the nurse recalls that it is normal to feel tactile fremitus most
intensely over which location?
a. Between the scapulae
b. Third intercostal space, MCL
c. Fifth intercostal space, midaxillary line (MAL)
d. Over the lower lobes, posterior side
A
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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:
a. Is caused by moisture in the alveoli.
b. Indicates that air is present in the subcutaneous tissues.
c. Is caused by sounds generated from the larynx.
d. Reflects the blood flow through the pulmonary arteries
C
During percussion, the nurse knows that a dull percussion note elicited over a lung lobe most
likely results from:
a. Shallow breathing.
b. Normal lung tissue.
c. Decreased adipose tissue.
d. Increased density of lung tissue.
D
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.
a. Side-to-side
b. Top-to-bottom
c. Posterior-to-anterior
, d. Interspace-by-interspace
A
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:
a. Normally auscultated over the trachea.
b. Bronchial breath sounds and normal in that location.
c. Vesicular breath sounds and normal in that location.
d. Bronchovesicular breath sounds and normal in that location.
C
We have an expert-written solution to this problem!
The nurse is auscultating the chest in an adult. Which technique is correct?
a. Instructing the patient to take deep, rapid breaths
b. Instructing the patient to breathe in and out through his or her nose
c. Firmly holding the diaphragm of the stethoscope against the chest
d. Lightly holding the bell of the stethoscope against the chest to avoid friction
C
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:
a. Dullness.
b. Tympany.
c. Resonance.
d. Hyperresonance.
A
During auscultation of the lungs, the nurse expects decreased breath sounds to be heard in
which situation?
a. When the bronchial tree is obstructed
b. When adventitious sounds are present
c. In conjunction with whispered pectoriloquy
d. In conditions of consolidation, such as pneumonia
A
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