NUR 216 EXAM 3 (ALL
ACCURATELY ANSWERED)
Question :Inspect and auscultate anterior chest
Correct 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
Question :Vertical chest landmarks
Correct 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
Question :Inspect and auscultate posterior chest
Correct 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
Question :Ventilation vs diffusion
Correct answer:Ventilation- exchange of O2 and CO2 in
the lungs
Diffusion- exchange of O2 and CO2 between alveoli and RBC, hypoxemia if not enough
Question :Overall chest inspection
Correct 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
Question :Respiratory effort evaluation
Correct 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
Question :Thorax percussion
Correct 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
Question :Respiratory Auscultation expected sounds
Correct answer:Eupnea, bronchial, bronchovesicular,
vesicular
Question :respiratory auscultation unexpected sounds
Correct answer:crackles/rales, wheezes, ronchi, pleural
friction rub, stridor, apnea
Question :eupnea
Correct answer:normal breathing
Question :bronchial
Correct answer:loud, high pitched, hollow quality,
expiration longer than inspiration over the trachea