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A patient has been diagnosed with heart failure that has not yet responded to treatment. What breath sound should the nurse expect to assess on auscultation?
- A. Expiratory wheezes
- B. Inspiratory wheezes
- C. Rhonchi
- D. Crackles
Correct Answer: D
Rationale: Crackles reflect underlying inflammation or congestion and are often present in such conditions as pneumonia, bronchitis, and congestive heart failure. Rhonchi and wheezes are associated with airway obstruction, which is not a part of the pathophysiology of heart failure.
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The nurse is assessing a newly admitted medical patient and notes there is a depression in the lower portion of the patients sternum. This patients health record should note the presence of what chest deformity?
- A. A barrel chest
- B. A funnel chest
- C. A pigeon chest
- D. Kyphoscoliosis
Correct Answer: B
Rationale: A funnel chest occurs when there is a depression in the lower portion of the sternum, and this may lead to compression of the heart and great vessels, resulting in murmurs. A barrel chest is characterized by an increase in the anteroposterior diameter of the thorax and is a result of overinflation of the lungs. A pigeon chest occurs as a result of displacement of the sternum and includes an increase in the anteroposterior diameter. Kyphoscoliosis, which is characterized by elevation of the scapula and a corresponding S-shaped spine, limits lung expansion within the thorax.
The nurse has assessed a patients family history for three generations. The presence of which respiratory disease would justify this type of assessment?
- A. Asthma
- B. Obstructive sleep apnea
- C. Community-acquired pneumonia
- D. Pulmonary edema
Correct Answer: A
Rationale: Asthma is a respiratory illness that has genetic factors. Sleep apnea, pneumonia, and pulmonary edema lack genetic risk factors.
While assessing a patient who has pneumonia, the nurse has the patient repeat the letter E while the nurse auscultates. The nurse notes that the patients voice sounds are distorted and that the letter A is audible instead of the letter E. How should this finding be documented?
- A. Bronchophony
- B. Egophony
- C. Whispered pectoriloquy
- D. Sonorous wheezes
Correct Answer: B
Rationale: This finding would be documented as egophony, which can be best assessed by instructing the patient to repeat the letter E. The distortion produced by consolidation transforms the sound into a clearly heard A rather than E. Bronchophony describes vocal resonance that is more intense and clearer than normal. Whispered pectoriloquy is a very subtle finding that is heard only in the presence of rather dense consolidation of the lungs. Sound is so enhanced by the consolidated tissue that even whispered words are heard. Sonorous wheezes are not defined as a voice sound, but rather as a breath sound.
A patient with a decreased level of consciousness is in a recumbent position. How should the nurse best assess the lung fields for a patient in this position?
- A. Inform that physician that the patient is in a recumbent position and anticipate an order for a portable chest x-ray.
- B. Turn the patient to enable assessment of all the patients lung fields.
- C. Avoid turning the patient, and assess the accessible breath sounds from the anterior chest wall.
- D. Obtain a pulse oximetry reading, and, if the reading is low, reposition the patient and auscultate breath sounds.
Correct Answer: B
Rationale: Assessment of the anterior and posterior lung fields is part of the nurses routine evaluation. If the patient is recumbent, it is essential to turn the patient to assess all lung fields so that dependent areas can be assessed for breath sounds, including the presence of normal breath sounds and adventitious sounds. Failure to examine the dependent areas of the lungs can result in missing significant findings. This makes the other given options unacceptable.
A sputum study has been ordered for a patient who has developed coarse chest crackles and a fever. At what time should the nurse best collect the sample?
- A. Immediately after a meal
- B. First thing in the morning
- C. At bedtime
- D. After a period of exercise
Correct Answer: B
Rationale: Sputum samples ideally are obtained early in the morning before the patient has had anything to eat or drink.