EXAM 3 20210405 C11 NUR310G.C Health Assessment PDF

EXAM 3: 20210405-C11 - NUR310G.
C - Health Assessment 5/26/21, 3:53 PM
EXAM 3
Due May 24 at 3pm Points 50 Questions 50
Available after May 24 at 8am Time Limit 80 Minutes
Attempt History
Attempt Time Score
LATEST Attempt 1 73 minutes 36 out of 50
Score for this quiz: 36 out of 50

Submitted May 24 at 2:18pm
This attempt took 73 minutes.
Question 1 0 / 1 pts
The nurse is caring for a patient after thoracic surgery to remove a part
of the lung. The nurse documents “subcutaneous emphysema” after
assessing which of these?
You Answered Booming sounds upon percussion.
Correct Answer A coarse, crackling sensation palpable over the skin surface.
An audible grating sound with breathing.
A palpable vibration with voice sounds.
https://dcn.instructure.com/courses/48397/quizzes/181762 Page 1 of 37
EXAM 3: 20210405-C11 - NUR310G.C - Health Assessment 5/26/21, 3:53 PM
Subcutaneous emphysema is not assessed with auscultation or

percussion. A palpable vibration with speech is tactile fremitus.
The nurse is examining an adult patient. During auscultation of the

lower lobes, the nurse notes clear, soft, low pitched breath sounds.
Inspiration is louder than expiration. What is the correct interpretation of
this finding?
These are diminished breath sounds, which are consistent with

emphysema.
These are bronchial breath sounds, which are abnormal in that location.
You Answered
These are bronchovesicular breath sounds, which are normal in that
location.
Correct Answer
These are vesicular breath sounds, which are normal in that location.
A client presents to the emergency department with asthma

exacerbation. What does the nurse expect to find upon examination?
Tracheal shift.
Purulent mucus production.
Correct!
Wheezing and accessory muscle use.
Presence of bronchophony.
Patients suffering an acute asthma attack are likely to exhibit

tachypnea, labored breathing, cyanosis, wheezing, cough, and
anxiety.
An adult client on a ventilator becomes acutely restless and agitated.

Which assessment finding alerts the nurse to a left pneumothorax?
Correct! Unequal chest expansion.
Increased tactile fremitus.
Dullness to percussion.
Presence of bronchial breath sounds.
With a pneumothorax, free air in the pleural space causes partial

or complete lung collapse. If the pneumothorax is large, then
tachypnea and cyanosis are evident. Unequal chest expansion,
decreased or absent tactile fremitus, tracheal deviation to the
unaffected side, decreased chest expansion, hyperresonant
percussion tones, and decreased or absent breath sounds are
found with the presence of pneumothorax.
The nurse is frequently assessing lung sounds in a client with a left

apical pnuemothorax. Where should the nurse place the stethoscope to
monitor this problem?
Correct! Supraclavicular area.
Fifth intercostal space in the midclavicular line (MCL).
Fourth interspace posteriorly.
Sixth rib laterally.
The apex of the lung on the anterior chest is 3 to 4 cm above the

inner third of the clavicles. On the posterior chest, the apices are
at the level of C7.
The neonatal nurse is completing a respiratory assessment on a

sleeping newborn infant. Which finding is considered a
normal variation?
Mild wheezing upon auscultation.
Diminished breath sounds.
Correct!
Irregular respiratory pattern with brief periods of apnea.
Nasal flaring with respiratory rate 50 breaths per minute..
Newborn respiratory rate is about 30-40 breaths/minute, but can

spoke up to 60 breaths/minute. The respiratory pattern may be
irregular with sleeping and brief periods of apnea less than 10-
15 seconds is common.
The nurse would most likely hear fine crackles in which patient?
Correct!
Infant born 1 hour ago.
A healthy 5-year-old child
A patient with a pneumothorax
A pregnant woman
Fine crackles are commonly heard in the immediate newborn

period as a result of the opening of the airways and a clearing of
fluid. Persistent fine crackles would be noticed with pneumonia,
bronchiolitis, or atelectasis. Fine crackles would not be expected
in the other options.
The nurse is examining a client with “flu-like symptoms.” While

auscultating the breath sounds, the nurse hears a low-pitched, grating
sound upon inspiration and expiration. The nurse suspects:
Correct! Inflammation of the pleura.
Asthma exacerbation.
Collapsed lung.
Atelectasis.
The assessment finding is consistent with a pleural friction rub,

which is heard with inflammation of the pleura.
The nurse is caring for a client admitted for heart failure exacerbation.
Which assessment finding alerts the nurse to the presence of
pulmonary edema?
Taut skin.
Correct!
Frothy sputum.
Abdominal distention.
Chest pain.
Clients with pulmonary edema (fluid accumulation in the air

spaces of the lungs) exhibit dyspnea, pink frothy sputum, and
fine crackles upon auscultation.
The nurse is examining a client with a long history emphysema. The

nurse is most likely to observe which of these?
Respiratory rate 10-24 breaths/minute.
Correct!
Widened anteroposterior diameter.
High-pitched breath sounds in the lower lobes.
Narrow costal angle.
Long-standing emphysema will result in hypertrophied

accessory muscles from aiding in forced respiration. Chest
expansion may be decreased but symmetric. Decreased tactile
fremitus occurs from decreased transmission of vibrations.
Percussion will reveal hyperresonance. An anteroposterior-to-
transverse diameter ratio of 1:1 or barrel chest is observed in
individuals with COPD because of hyperinflation of the lungs.
The ribs are more horizontal, and the chest appears as if held in
continuous inspiration. Costal angle is widened.
The nurse is examining a 3-year-old child. Which of these findings

would the nurse expect?
Productive cough.
Correct! Moderately-pitched breath sounds in peripheral lung fields
Crepitus palpated at the costochondral junctions
Irregular respiratory pattern and a respiratory rate of 40 breaths per

minute at rest
Bronchovesicular breath sounds in the peripheral lung fields of

the infant and young child up to age 5 or 6 years are normal
findings. Their thin chest walls with underdeveloped musculature
do not dampen the sound, as do the thicker chest walls of
adults; therefore, breath sounds are loud and harsh. Crepitus is
not a normal or expected finding in a child or any age patient.
Although the technique of measuring diaphragmatic excursion
using percussion is no longer recommended, you would still
expect to see diaphragmatic excursion (movement of the
diaphragm) in a 4-year-old child. The normal respiratory rate for
a 4-year-old child is 20 to 24, so a respiratory rate of 40 while at
rest would be tachypnea.
A patient has been admitted to the hospital and reports significant pain
with breathing and coughing. Which finding alert the nurse to suspect
pleuritis?
Wheezing
Crackles
Correct! Friction rub
Stridor
A patient with pleuritis will exhibit a pleural friction rub upon

auscultation. This sound is made when the pleurae become
inflamed and rub together during respiration. The sound is
superficial, coarse, and low-pitched, as if two pieces of leather
are being rubbed together. Stridor is associated with croup,
acute epiglottitis in children, and foreign body inhalation.
Crackles are associated with pneumonia, heart failure, chronic
bronchitis, and other diseases. Wheezes are associated with
diffuse airway obstruction caused by acute asthma or chronic
emphysema.
When assessing a patient’s lungs, what should the nurse recall about
the right lung?
Correct!
Is shorter than the left lung.
Extends down to the 8th interspace.
Consists of two lobes.
Is narrower due to the heart,
The right lung has three lobes and is shorter than the left lung
because of the underlying liver.
The nurse is examining a hospitalized client and observes respirations

that are very shallow and irregular, at 10 breaths per minute. What is
the most likely cause of this finding?
Correct! Recent opioid administration.
Pneumonia.
Diabetic ketoacidosis.
Fever.
Hypoventilation is characterized by an irregular, shallow pattern,

and can be caused by an overdose of narcotics or anesthetics.
Bradypnea is slow breathing, with a rate less than 10
respirations per minute.
The nurse is assessing the lungs of an older adult. Which of these

changes are normal in the respiratory system of the older adult?
You Answered
Decrease in small airway closure occurs, leading to problems with
atelectasis.
Severe dyspnea is experienced on exertion, resulting from changes in

the lungs.
Correct Answer
Lungs are less elastic and distensible, which decreases their ability to
collapse and recoil.
Respiratory muscle strength increases to compensate for a decreased

vital capacity.
In the aging adult, the lungs are less elastic and distensible,
which decreases their ability to collapse and recoil. Vital capacity
is decreased, and a loss of intra-alveolar septa occurs, causing
less surface area for gas exchange. The lung bases become
less ventilated, and the older person is at risk for dyspnea with
exertion beyond his or her usual workload.
Which statement is true regarding older adults and the respiratory

system?
It may be normal to hear bronchial breath sounds throughout the lungs

of an older adult due to anatomical changes within the thorax.
The older adult takes slower, deeper breaths compared to a middle-

aged adult which increased their risk for acidosis.
Older adults have a decreased anteroposterior diameter due to

curvature of the thoracic spine.
Correct!
Decreased ability to cough and a los of protective airway reflexes
increases the older adult's risk for postoperative pulmonary
complications.
The costal cartilages become calcified with aging, resulting in a

less mobile thorax. Alveoli die off, and a shallow breathing
patterns in addition to weaker coughing and a decreased gag
reflex increases their risk for postoperative complications.
A homeless adult male is being seen in the clinic for "cough." Interview
reveals "brownish-red" sputum, fevers, and "waking up drenched in
sweat". Based on these findings, what is the most likely cause?
Pulmonary edema
Correct!
Tuberculosis
Pleuritis.
Chronic Bronchitis
Sputum is not diagnostic alone, but some conditions have

characteristic sputum production. Tuberculosis often produces
rust-colored sputum in addition to other symptoms of night
sweats and low-grade afternoon fevers. Pneumonia typically
presents with yellow-green sputum and pink, frothy sputum is
characteristic of pulmonary edema. Bronchitis alone usually has
a dry, not productive, cough.
During percussion, the nurse hears a muffled thud over a lung lobe.
What is the most likely cause of this finding?
Correct Answer Increased density of lung tissue.
You Answered Pneumothorax.
Normal lung tissue
Hyperinflation due to emphysema.
A dull percussion note indicates an abnormal density in the

lungs, as with pneumonia, pleural effusion, atelectasis, or a
tumor. Resonance is the expected finding in normal lung tissue.
An adult is brought to the emergency department after being found on

the floor at home. The patient’s respirations are fast and deep with a
rate of 40 respirations per minute. What is the most likely cause of this
finding?
Narcotic use.
Atelectasis.
Correct!
Metabolic acidosis.
Inflammation of the pleura.
Hyperventilation is characterized by an increase in both rate and

depth, and it can be caused by extreme exertion, anxiety, or
alterations that cause metabolic acidosis including salicylate OD
or DKA.
The nurse is performing a focused respiratory assessment of a client

who is in severe respiratory distress two days after abdominal surgery.
What is most important for the nurse to assess?
Correct Answer Auscultation of bilateral breath sounds.
You Answered
Palpation for increased or decreased tactile fremitus.
Obtaining respiratory rate by counting for a full minute.
Percussion of anterior and posterior lung fields.
Percussion, palpation of tactile fremitus, and assessment of

chest expansion both anteriorly and posteriorly are time
consuming, require significant patient cooperation, and will not
give you as much valuable information as auscultation.
The nurse is examining a patient with heart failure. What data leads to
the nurse to suspect a pleural effusion?
Bradypnea.
Drum-like notes upon percussion.
Correct! Decreased chest expansion.
Positive fluid wave test.
Pleural effusions often cause decreased and/or asymmetric

chest expansion and shortness of breath and tachypnea.
The nurse suspects intraabdominal fluid collection in a patient

presenting with heart failure exacerbation. Which of these procedures
are appropriate for the nurse to use when assessing for ascites? Select
all that apply.
You Answered Assess for rebound tenderness on the left side of the abdomen.
You Answered Ask the supine client to flex the right hip against resistance.
You Answered Percuss for costovertebral angle tenderness.
Correct Answer Test for a fluid wave across the abdomen.
Correct Answer Measure abdominal girth on a daily basis.
Correct Answer Percuss the abdomen for shifting dullness.
Testing for the rebound tenderness and performing the iliopsoas

muscle test should be used when assessing for appendicitis.
Costovertebral angle tenderness is consistent with kidney
inflammation.
Which of the following conditions may result in the nurse auscultating

hyperactive bowel sounds? Select All That Apply.
Post-abdominal surgery
Correct!
Early bowel obstruction
Peritonitis
Opioid use.
Correct!
Laxative use
Correct!
Gastroenteritis
Hyperactive bowel sounds are heard with increased motility,

such as with gastroenteritis, laxative use, early bowel
obstruction, hunger, and diarrhea.
The nurse is performing a respiratory examination on an adult client.

Which of these findings are normal? (Select all that apply).
Correct Answer
The intensity of palpable vibrations decreases as the nurse moves to
the bases of the lungs.
Palpable crepitus over the chest wall.
Faint wheezes upon auscultation of the posterior thorax.
You Answered Anteroposterior diameter is greater than the transverse diameter.
Correct Answer
During auscultation of voice sounds, the whispered "1-2-3" sounds faint
and indistinct.
You Answered Percussion of the lung fields reveals areas of flatness.
The nurse is preparing to examine a client with "abdominal pain and

vomiting." Which of these procedures are appropriate for use when
assessing for appendicitis or a perforated appendix? Select all that
apply.
Test for shifting dullness
Correct!
Test for the Blumberg sign
Test for a fluid wave
Test for the Murphy sign
Correct!
Perform the iliopsoas muscle test
Correct! Assess for McBurney's point tenderness.
Testing for the Blumberg sign (rebound tenderness) and

performing the iliopsoas muscle test should be used when
assessing for appendicitis.
Pneumonia can be caused by all of the following, except:
Fungal infection.
Correct!
Vaccinations.
Aspiration of food or liquid.
Bacterial consolidation.
A patient with a history of diabetes presents to their primary care

provider with “abdominal pain.” After bringing the patient to the
examination room, what should the nurse do first?
Strain the urine for debris.
Percuss for costovertebral tenderness.
Correct!
Perform a full pain assessment.
Assess for rebound tenderness.
The nurse should obtain subjective data (full pain assessment -

OPQRSTU) before obtaining objective data.
An adult client is being treated for lobar pneumonia. Which collection of

signs/symptoms is most likely to be found in this patient?
A congested cough and decreased voice sounds.
You Answered
Wheezing upon auscultation and decreased fremitus.
Hyperresonance to percussion and cyanosis.
Correct Answer Tachycardia and crackles upon auscultation.
Hyperresonance, decreased voice sounds, and decreased

fremitus is not consistent with lobar PNA.
A mother brings her 3 month-old infant to the clinic for “cold symptoms.”
When performing the physical assessment, the nurse notes that the
child has nasal flaring and subscostal retractions. The nurse’s next
action should be to:
Conduct the rest of the head-to-toe examination.
Reassure the mother that these are normal symptoms of a cold.
Percuss the lungs fields.
Correct!
Apply a pulse oximeter and contact the provider.
The infant is an obligatory nose breather until the age of 3

months. Normally, no flaring of the nostrils and no sternal or
intercostal retraction occurs. Nasal flaring and retractions of the
sternum and intercostal muscles indicate increased inspiratory
effort, as in pneumonia, acute airway obstruction, asthma, and
atelectasis; therefore, immediate referral to the physician is
warranted.
The nurse is examining a client with severe ascites and expects to

assess:
Rounded contour with loose abdominal skin.
Soft abdomen with sunken umbilicus.
Hyperactive bowel sounds.
Correct!
Protuberant abdominal contour with everted umbilicus.
Severe ascites results in a taut, protuberant abdomen with

everted umbilicus and bulging flanks when supine.
An adult client presents to the emergency department with "difficulty

breathing.” General survey reveals anxiety, accessory muscle use, and
dry cough. The nurses first action would be to:
You Answered Assist the client to a supine position for a full respiratory exam.
Assume asthma exacerbation and prepare a nebulizer treatment.
Administer 2 liters oxygen via nasal cannula.
Correct Answer
Auscultate lung fields and obtain an oxygen saturation.
The respiratory exam should be done while the client is sitting

up, if possible. Interventions should be
chosen based on the assessment data.
The nurse is caring for a client with worsening heart failure. Which
technique should the nurse use first to monitor for the early onset of
ascites in this hospitalized client?
Correct Answer Measure abdominal girth on a routine basis.
Test for a fluid wave on the abdomen.
Percuss for shifting dullness.
You Answered Palpate deeply to assess for rebound tenderness.
Fluid wave and shifting dullness are seen only with large
amounts of fluid. Rebound tenderness is associated with
peritonitis, not ascites.
Upon examination of a patient presenting with "abdominal pain," the

nurse hears high-pitched, gurgling sounds in the right lower and upper
quadrants. What should the nurse do next?
Re-listen to those quadrants and count the sounds to determine if they

are hyperactive.
Percuss all quadrants.
Correct!
Auscultate the other two quadrants.
Assume bowel obstruction and notify the provider.
Normoactive bowel sound are high-pitched and gurgling.

All 4 quadrants should be assessed.
A nurse educator is teaching new graduate nurses about pneumonia,

including signs/symptoms, prevention, and treatment. What should the
nurse educator include in the teaching?
You Answered
Decreased fremitus and hyperresonance upon percussion will be
present.
Antibiotics are used to treat all types of pneumonia.
Flu vaccination will not help to reduce one's risk of developing

pneumonia
Correct Answer Cough and chest pain are common symptoms of pneumonia.
Increased fremitus and dullness to percussion are common

assessment findings. Only bacterial PNA is treated with
antibiotics (not viral or fungal). Flu can cause pneumonia.
All of these statements about the sternal angle are true, except:
It marks the site of tracheal bifurcation into the right and left bronchi.
Correct! It should be 90 degrees.
It is continuous with the second rib.
It is the articulation of the manubrium and body of the sternum.
The costal angle should be 90 degrees.
The nurse is aware that what change may occur in the gastrointestinal
system with aging?
You Answered Increased esophageal emptying.
Frequent, loose stools.
Correct Answer
Decreased liver size.
Increased salivation.
Gastric acid secretion decreases with aging. As one ages,

salivation decreases, esophageal emptying is delayed, and liver
size decreases.
An elderly patient has been diagnosed with pernicious anemia. The

nurse knows this is due to:
Impaired release of gastric acid which result in fat and protein

malabsorption.
Delayed gastrointestinal emptying time which results in pyrosis.
Correct!
Decreased gastric acid secretion which inhibits Vitamin B12 absorption.
Decreased taste and smell which results in appetite changes.
Gastric acid secretion decreases with aging and may cause

pernicious anemia (because it interferes with vitamin B12
absorption), iron deficiency anemia, and malabsorption of
calcium.
During an assessment of a 1 month-old, the nurse notices that the

umbilicus appears midline, enlarged, and everted. The abdomen is soft
to palpation, and the skin is pink and warm. The nurse suspects which
condition?
Correct!
Umbilical hernia.
Intra-abdominal bleeding.
Constipation.
Ascites.
The umbilicus is normally midline and inverted with no signs of

discoloration. With an umbilical hernia, the mass is enlarged and
everted. The other responses are incorrect.
The nurse is examining an adult client. At which point does the nurse
expect to hear dullness upon percussion?
Second intercostal spaces bilaterally.
Supraclavicular areas.
Correct! Seventh intercostal space at the right midclavicular line.
Third intercostal space, left midclavicular line.
The liver is a solid organ which is located in the right

upper quadrant and would elicit a dull percussion note. Dullness
may be noted from the 5th-8th ICS on the right.
While caring for a client after hip replacement surgery, the nurse notices
that a patient has had a large black, tarry stool. The nurse suspects:
Decreased fat absorption.
Localized rectal bleeding.
Correct! Gastrointestinal bleeding.
Use of iron supplements.
Black stools may be tarry as a result of occult blood (melena)

from gastrointestinal bleeding.
During an interview, a client reports that his stools have recently been
large, "very smelly," and look "oily." The nurse suspects:
Correct!
Fat malabsorption.
Constipation.
Gastric bleeding.
Localized rectal bleeding.
Steatorrhea is the excretion of abnormal quantities of fat with the

feces owing to reduced absorption of fat by the intestine. Stools
are often bulgier, foul-smelling, and pale.
The nurse is examining a client presenting with "abdominal pain".

Which of these assessment findings alerts the nurse to an abdominal
aortic aneurysm?
Correct!
Strong pulsating mass just above the umbilicus.
Musical, drumlike notes heard upon percussion.
Rounded abdominal contour with striae.
Absence of vascular sounds.
Most aortic aneurysms are palpable during routine examination

and feel like a pulsating mass. A bruit will be audible, and
femoral pulses are present but decreased.
The nurse is performing an abdominal examination on an adult client

with hypertension. Which finding should be reported to the provider?
Rounded abdominal contour.
Concave, midline umbilicus.
High-pitched bowel sounds heard every few seconds.
Correct! Loud vascular sounds heard with the bell.
Bruits are not normally heard over the abdomen, and they can
indicate stenosis or aneurysm. The other options are normal.
The nurse is reassessing an adolescent client who is scheduled for an

appendectomy in 4 hours. The client presses his call light and tells
the nurse his stomach is "hurting way more." Which assessment finding
alerts the nurse to immediately notify the provider?
Temperature 99.1 Fahrenheit.
Correct! Sudden onset of abdominal rigidity.
Presence of hypoactive bowel sounds.
Small amount of clear emesis.
Abdominal rigidity is consistent with peritonitis which can result

from a ruptured appendix.
The nurse is caring for a post-operative patient who has not urinated in
6 hours. How should the nurse first assess for urinary retention?
You Answered Auscultate for rushing sounds near the groin.
Correct Answer Percuss and palpate the suprapubic area.
Test for shifting dullness over the abdomen.
Perform a straight catheterization.
A straight cath may be needed if the patient is retaining urine,

but the patient should be assessed first. Auscultation and a fluid
wave test are not used to assess for urinary retention.
The nurse is examining an adolescent client presenting with "fatigue

and sore throat." During palpation of the abdomen, the nurse notes a
palpable mass in the left upper quadrant. The nurse suspects:
A normal finding.
Correct Answer Splenomegaly.
You Answered Appendicitis.
Cholecystitis.
The gallbladder is in the right upper quadrant, the sigmoid colon

is in the left lower quadrant, and the appendix is in the right
lower quadrant. This is not a normal finding.
A patient presents to the clinic complaining of "epigastric pain for one

week". History of Present Illness reveals that the pain is “gnawing” and
"worse in the middle of the night." The nurse suspects:
Ulcerative Colitis.
Correct! Peptic Ulcer Disease.
Cholecystitis.
Appendicitis.
Jarvis p. 562. Peptic Ulcer pain is dull, aching, gnawing pain that
may be relieved with food and may awaken the person from
sleep. Pain associated with duodenal ulcers occurs 2 to 3 hours
after a meal; it may be relieved by eating more food.
The nurse is preparing to perform an abdominal exam. Which method

will the nurse utilize during this exam?
Correct! Inquire about painful areas and examine those areas last.
Inspect, palpate, percuss, then auscultate the quadrants.
Utilize dim lighting to assist in relaxation.
Assist the patient to a Semi-Fowler's position with their arms above their
head.
Examine painful areas last to avoid muscle guarding
The nurse is assessing an adult male client presenting with "abdominal

pain". Which finding is considered normal?
Protuberant abdominal contour.
Pulsatile, whooshing sounds heard during auscultation with the bell.
Correct! Drumlike notes heard during percussion.
Dark, tarry stools.
Upon percussion of the abdomen, tympany (a musical, drumlike

note) usually predominates as air in the intestines rises to the
surface when the person is supine.
Which structure is located in the right lower quadrant of the abdomen?
Duodenum
Sigmoid colon
Gallbladder
Correct!
Appendix
The appendix is located in the RLQ.
Quiz Score: 36 out of 50

EXAM 3 20210405 C11 NUR310G.C Health Assessment PDF

Uploaded by

Copyright:

Available Formats

EXAM 3 20210405 C11 NUR310G.C Health Assessment PDF

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

EXAM 3 20210405 C11 NUR310G.C Health Assessment PDF

Uploaded by

Copyright:

Available Formats

EXAM 3: 20210405-C11 - NUR310G.

C - Health Assessment 5/26/21, 3:53 PM

Score for this quiz: 36 out of 50

You Answered Booming sounds upon percussion.

An audible grating sound with breathing.

A palpable vibration with voice sounds.

Subcutaneous emphysema is not assessed with auscultation or

The nurse is examining an adult patient. During auscultation of the

These are diminished breath sounds, which are consistent with

A client presents to the emergency department with asthma

Purulent mucus production.

Patients suffering an acute asthma attack are likely to exhibit

An adult client on a ventilator becomes acutely restless and agitated.

Correct! Unequal chest expansion.

Increased tactile fremitus.

Presence of bronchial breath sounds.

With a pneumothorax, free air in the pleural space causes partial

The nurse is frequently assessing lung sounds in a client with a left

Correct! Supraclavicular area.

Fifth intercostal space in the midclavicular line (MCL).

Fourth interspace posteriorly.

Sixth rib laterally.

The apex of the lung on the anterior chest is 3 to 4 cm above the

The neonatal nurse is completing a respiratory assessment on a

Mild wheezing upon auscultation.

Diminished breath sounds.

Nasal flaring with respiratory rate 50 breaths per minute..

Newborn respiratory rate is about 30-40 breaths/minute, but can

A healthy 5-year-old child

A patient with a pneumothorax

Fine crackles are commonly heard in the immediate newborn

The nurse is examining a client with “flu-like symptoms.” While

Correct! Inflammation of the pleura.

The assessment finding is consistent with a pleural friction rub,

Clients with pulmonary edema (fluid accumulation in the air

The nurse is examining a client with a long history emphysema. The

Respiratory rate 10-24 breaths/minute.

High-pitched breath sounds in the lower lobes.

Narrow costal angle.

Long-standing emphysema will result in hypertrophied

The nurse is examining a 3-year-old child. Which of these findings

Correct! Moderately-pitched breath sounds in peripheral lung fields

Crepitus palpated at the costochondral junctions

Irregular respiratory pattern and a respiratory rate of 40 breaths per

Bronchovesicular breath sounds in the peripheral lung fields of

Correct! Friction rub

A patient with pleuritis will exhibit a pleural friction rub upon

Extends down to the 8th interspace.

Consists of two lobes.

Is narrower due to the heart,

The nurse is examining a hospitalized client and observes respirations

Correct! Recent opioid administration.

Hypoventilation is characterized by an irregular, shallow pattern,

The nurse is assessing the lungs of an older adult. Which of these

Severe dyspnea is experienced on exertion, resulting from changes in

Respiratory muscle strength increases to compensate for a decreased

Which statement is true regarding older adults and the respiratory

It may be normal to hear bronchial breath sounds throughout the lungs

The older adult takes slower, deeper breaths compared to a middle-