NSG 3160 Exam 3

1. Which of these statements is true regarding the ver- tebra prominens? The vertebra prominens is: 2. When performing a respiratory assessment on a pa- The spinous process of C7. A normal finding in a tient, the nurse notices a costal angle of approximate- healthy adult. ly 90 degrees. This characteristic is: 3. When assessing a patients lungs, the nurse recalls that the left lung: Consists of two lobes. 4. Which statement about the apices of the lungs is true? Extend 3 to 4 cm above the The apices of the lungs: 5. During an examination of the anterior thorax, the nurse is aware that the trachea bifurcates anteriorly at the: inner third of the clavicles. Sternal angle 6. During an assessment, the nurse knows that expected Muffled voice sounds and assessment findings in the normal adult lung include the presence of: symmetric tactile fremitus. 7. The primary muscles of respiration include the: Diaphragm and inter- costals. 8. A 65-year-old patient with a history of heart failure Assessing for other signs comes to the clinic with complaints of being awakened and symptoms of paroxys- from sleep with shortness of breath. Which action by the nurse is most appropriate? mal nocturnal dyspnea 9. When assessing tactile fremitus, the nurse recalls that Between the scapulae it is normal to feel tactile fremitus most intensely over which location? The nurse is reviewing the technique of palpating for Is caused by sounds gen- tactile fremitus with a new graduate. Which statement erated from the larynx. by the graduate nurse reflects a correct understand- ing of tactile fremitus? Tactile fremitus: 11. Tactile Fremitus is what? Palpable vibration 12. During percussion, the nurse knows that a dull percus- Increased density of lung sion note elicited over a lung lobe most likely results from: 13. The nurse is observing the auscultation technique of another nurse. The correct method to use when pro- gressing from one auscultatory site on the thorax to another is comparison. 14. When auscultating the lungs of an adult patient, the nurse notes that low-pitched, soft breath sounds are tissue. Side-to-side Vesicular breath sounds and normal in that loca- heard over the posterior lower lobes, with inspiration tion. being longer than expiration. The nurse interprets that these sounds are: 15. 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: Dullness 16. The nurse is auscultating the chest in an adult. Which Firmly holding the di- technique is correct? 17. During auscultation of the lungs, the nurse expects decreased breath sounds to be heard in which situa- tion? aphragm of the stetho- scope against the chest When the bronchial tree is obstructed 18. The nurse knows that a normal finding when assess- ing the respiratory system of an older adult is: 19. A mother brings her 3-month-old infant to the clinic Decreased mobility of the thorax. Recognize that these are for evaluation of a cold. She tells the nurse that he has serious signs, and contact had a runny nose for a week. When performing the physical assessment, the nurse notes that the child has nasal flaring and sternal and intercostal retrac- tions. The nurses next action should be to: