NUR 216 Exam 3
Inspect and auscultate anterior chest - Answer- Assess with the client sitting, lying, or standing
Inspect and auscultate the anterior chest
Assess for shape and symmetry of the chest wall
Identify tachypnea, bradypnea, and hypoventilation
Vertical chest landmarks
Ant...
NUR 216 Exam 3
Inspect and auscultate anterior chest - Answer- Assess with the client sitting, lying,
or standing
Inspect and auscultate the anterior chest
Assess for shape and symmetry of the chest wall
Identify tachypnea, bradypnea, and hypoventilation
Vertical chest landmarks
Anterior thorax- along the midclavicular lines, bilaterally, asses for accessory muscle
use
Maximize sounds by-Have the client take deep breaths with an open mouth each
time you move the stethoscope
Place diaphragm directly on the skin
Vertical chest landmarks - Answer- Midsternal line- through the center of the sternum
Midclavicular line- through the midpoint of the clavicle
Anterior axillary line- through the apex of the axillae
Posterior axillary line- through the posterior axillary fold
Right and left scapular lines- through the inferior angle of the scapula
Vertebral line-along the center of the spine
Inspect and auscultate posterior chest - Answer- Identify shape and symmetry of the
chest wall
Retractions
Posterior thorax while sitting or standing
Percussion and auscultation sites
Between the scapula and the vertebrae of the back,
below the scapula along the right and left scapula line
Ventilation vs diffusion - Answer- Ventilation- exchange of O2 and CO2 in the lungs
Diffusion- exchange of O2 and CO2 between alveoli and RBC, hypoxemia if not
enough
Overall chest inspection - Answer- Shape- the anteroposterior diameter is one third
to one half of the transverse diam
Symmetry- the chest is symmetric with no deformities of the ribs, sternum, scapula
or vertebrae, and equal movements during respiration
, ICS- no excessive retractions
Respiratory effort
Respiratory effort evaluation - Answer- Between 12-20 breaths per min
Character of breathing- diaphragmatic, abdominal and thoracic
Use of accessory muscle
Chest wall expansion
Depth of respirations-unlabored, quiet breathing
Cough- if productive, not the color and consistency
Trachea- midline
Thorax percussion - Answer- Compare both sides to each other
Unexpected findings
Dullness- in fluid or solid tissue, this can indicate pneumonia or a tumor
Hyperresonance- in the presence of air, this can indicate pneumothorax or
emphysema
bronchial - Answer- loud, high pitched, hollow quality, expiration longer than
inspiration over the trachea
Bronchovesicular - Answer- medium pitch, blowing sounds and intensity with equal
inspiration and expiration times over the larger airways
Vesicular - Answer- soft, low-pitched breezy sounds,inspiration three times longer
than expiration over most peripheral areas of the lungs
crackles (rales) - Answer- fine to coarse bubbly sounds (not cleared with coughing)
as air passes through fluid or re-expands collapses small airways
wheezes - Answer- high-pitched whistling musical sounds as air passes through
narrowed or obstructed airways, usually louder on expiration
ronchi - Answer- coase, loud, low-pitched rumbling sounds during either, inspiration
or expiration resulting from fluid or mucus, can clear with coughing
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