When assessing tactile fremitus, the nurse recalls that it is normal

Which of these statements is true regarding the vertebra prominens? The vertebra prominens is:
A) the spinous process of C7.
B) usually not palpable in most individuals.
C) opposite the interior border of the scapula.
D) located next to the manubrium of the sternum.

When performing a respiratory assessment on a patient, the nurse notices a costal angle of approximately 90 degrees. This characteristic is:
A) seen in patients with kyphosis.
B) indicative of pectus excavatum.
C) a normal finding in a healthy adult.
D) an expected finding in a patient with a barrel chest.

When assessing a patient’s lungs, the nurse recalls that the left lung:
A) consists of two lobes.
B) is divided by the horizontal fissure.
C) consists primarily of an upper lobe on the posterior chest.
D) is shorter than the right lung because of the underlying stomach.

Which statement about the apices of the lungs is true? The apices of the lungs:
A) are at the level of the second rib anteriorly.
B) extend 3 to 4 cm above the inner third of the clavicles.
C) are located at the sixth rib anteriorly and the eighth rib laterally.
D) rest on the diaphragm at the fifth intercostal space in the midclavicular line.

During an examination of the anterior thorax, the nurse keeps in mind that the trachea bifurcates anteriorly at the:
A) costal angle.
B) sternal angle.
C) xiphoid process.
D) suprasternal notch.

During an assessment, the nurse knows that expected assessment findings in the normal adult lung include the presence of:
A) adventitious sounds and limited chest expansion.
B) increased tactile fremitus and dull percussion tones.
C) muffled voice sounds and symmetrical tactile fremitus.
D) absent voice sounds and hyperresonant percussion tones.

The primary muscles of respiration include the:
A) diaphragm and intercostals.
B) sternomastoids and scaleni.
C) trapezius and rectus abdominis.
D) external obliques and pectoralis major.

A 65-year-old patient with a history of heart failure comes to the clinic with complaints of “being awakened from sleep with shortness of breath.” Which action by the nurse is most appropriate?
A) Obtain a detailed history of the patient’s allergies and history of asthma.
B) Tell the patient to sleep on his or her right side to facilitate ease of respirations.
C) Assess for other signs and symptoms of paroxysmal nocturnal dyspnea.
D) Assure the patient that this is normal and will probably resolve within the next week.

When assessing tactile fremitus, the nurse recalls that it is normal to feel tactile fremitus most intensely over which location?
A) Between the scapulae
B) Third intercostal space, MCL
C) Fifth intercostal space, MAL
D) Over the lower lobes, posterior side

The nurse is reviewing the technique of palpating for tactile fremitus with a new graduate. Which statement by the graduate nurse reflects a correct understanding of tactile fremitus? “Tactile fremitus:
A) is caused by moisture in the alveoli.”
B) indicates that there is air in the subcutaneous tissues.”
C) is caused by sounds generated from the larynx.”
D) reflects the blood flow through the pulmonary arteries.”

During percussion, the nurse knows that a dull percussion note elicited over a lung lobe most likely results from:
A) shallow breathing.
B) normal lung tissue.
C) decreased adipose tissue.
D) increased density of lung tissue.

The nurse is observing the auscultation technique of another nurse. The correct method to use when progressing from one auscultatory site on the thorax to another is ____ comparison.
A) side-to-side
B) top-to-bottom
C) posterior-to-anterior
D) interspace-by-interspace

When auscultating the lungs of an adult patient, the nurse notes that over the posterior lower lobes low-pitched, soft breath sounds are heard, with inspiration being longer than expiration. The nurse interprets that these are:
A) sounds normally auscultated over the trachea.
B) bronchial breath sounds and are normal in that location.
C) vesicular breath sounds and are normal in that location.
D) bronchovesicular breath sounds and are normal in that location.

The nurse is auscultating the chest in an adult. Which technique is correct?
A) Instruct the patient to take deep, rapid breaths.
B) Instruct the patient to breathe in and out through his or her nose.
C) Use the diaphragm of the stethoscope held firmly against the chest.
D) Use the bell of the stethoscope held lightly against the chest to avoid friction.

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 would reveal:
A) dullness.
B) tympany.
C) resonance.
D) hyperresonance.

During auscultation of the lungs, the nurse expects decreased breath sounds to be heard in which situation?
A) When the bronchial tree is obstructed
B) When adventitious sounds are present
C) In conjunction with whispered pectoriloquy
D) In conditions of consolidation, such as pneumonia

18. The nurse knows that a normal finding when assessing the respiratory system of an elderly adult is:
A) increased thoracic expansion.
B) decreased mobility of the thorax.
C) a decreased anteroposterior diameter.
D) bronchovesicular breath sounds throughout the lungs.

21. When inspecting the anterior chest of an adult, the nurse should include which assessment?
A) Diaphragmatic excursion
B) Symmetric chest expansion
C) The presence of breath sounds
D) The shape and configuration of the chest wall

23. During an assessment of an adult, the nurse has noted unequal chest expansion and recognizes that this occurs in which situation?
A) An obese patient
B) When part of the lung is obstructed or collapsed
C) When bulging of the intercostal spaces is present
D) When accessory muscles are used to augment respiratory effort

During auscultation of the lungs of an adult patient, the nurse notices the presence of bronchophony. The nurse should assess for signs of which condition?
A) Airway obstruction
B) Emphysema
C) Pulmonary consolidation
D) Asthma

The nurse is reviewing the characteristics of breath sounds. Which statement about bronchovesicular breath sounds is true? They are:
A) musical in quality.
B) usually pathological.
C) expected near the major airways.
D) similar to bronchial sounds except that they are shorter in duration.

The nurse is listening to the breath sounds of a patient with severe asthma. Air passing through narrowed bronchioles would produce which of these adventitious sounds?
A) Wheezes
B) Bronchial sounds
C) Bronchophony
D) Whispered pectoriloquy

A patient has a long history of chronic obstructive pulmonary disease. During the assessment, the nurse is most likely to observe which of these?
A) Unequal chest expansion
B) Increased tactile fremitus
C) Atrophied neck and trapezius muscles
D) An anteroposterior-to-transverse diameter ratio of 1:1

A teenage patient comes to the emergency department with complaints of an inability to breathe and a sharp pain in the left side of his chest. The assessment findings include cyanosis, tachypnea, tracheal deviation to the right, decreased tactile fremitus on the left, hyperresonance on the left, and decreased breath sounds on the left. The nurse interprets that these assessment findings are consistent with:
A) bronchitis.
B) a pneumothorax.
C) acute pneumonia.
D) an asthmatic attack.

An adult patient with a history of allergies comes to the clinic complaining of wheezing and difficulty in breathing when working in his yard. The assessment findings include tachypnea, use of accessory neck muscles, prolonged expiration, intercostal retractions, decreased breath sounds, and expiratory wheezes. The nurse interprets that these assessment findings are consistent with:
A) asthma.
B) atelectasis.
C) lobar pneumonia.
D) heart failure.

The nurse is assessing the lungs of an older adult. Which of these describes normal changes in the respiratory system of the older adult?
A) Severe dyspnea is experienced on exertion resulting from changes in the lungs.
B) Respiratory muscle strength increases to compensate for a decreased vital capacity.
C) There is a decrease in small airway closure, leading to problems with atelectasis.
D) The lungs are less elastic and distensible, which decreases their ability to collapse and recoil.

When considering the biocultural differences in the respiratory systems, the nurse knows that which statement is true?
A) The smallest chest volumes are found in Asians.
B) The largest chest volumes are found in whites.
C) Asians are most likely to develop asthma.
D) Racial differences are of no significance when assessing the respiratory system.

33. A 35-year-old recent immigrant is being seen in the clinic for complaints of a cough that is associated with rust-colored sputum, low-grade afternoon fevers, and night sweats for the past 2 months. The nurse’s preliminary analysis, based on this history, is that this patient may be suffering from:
A) bronchitis.
B) pneumonia.
C) tuberculosis.
D) pulmonary edema.

A 70-year-old patient is being seen in the clinic for severe exacerbation of his heart failure. Which of these findings is the nurse most likely to observe in this situation?
A) Shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, ankle edema
B) Rasping cough, thick mucoid sputum, wheezing, bronchitis
C) Productive cough, dyspnea, weight loss, anorexia, tuberculosis
D) Fever, dry nonproductive cough, diminished breath sounds

A patient comes to the clinic complaining of a cough that is worse at night but not as bad during the day. The nurse recognizes that this may indicate:
A) pneumonia.
B) postnasal drip or sinusitis.
C) exposure to irritants at work.
D) chronic bronchial irritation from smoking.

During auscultation of breath sounds, the nurse should use the stethoscope correctly, in which of the following ways?
A) Listen to at least one full respiration in each location.
B) Listen as the patient inhales and then go to the next site during exhalation.
C) Have the patient breathe in and out rapidly while the nurse listens to the breath sounds.
D) If the patient is modest, listen to sounds over his or her clothing or hospital gown.

A patient has been admitted to the emergency department with a possible medical diagnosis of pulmonary embolism. The nurse expects to see which assessment findings related to this condition?
A) Absent or decreased breath sounds
B) Productive cough with thin, frothy sputum
C) Chest pain that is worse on deep inspiration, dyspnea
D) Diffuse infiltrates with areas of dullness upon percussion

During palpation of the anterior chest wall, the nurse notices a coarse, crackling sensation over the skin surface. On the basis of these findings, the nurse suspects:
A) tactile fremitus.
B) crepitus.
C) friction rub.
D) adventitious sounds.

The nurse is auscultating the lungs of a patient who had been sleeping and notices short, popping, crackling sounds that stop after a few breaths. The nurse recognizes that these breath sounds are:
A) atelectatic crackles, and that they are not pathologic.
B) fine crackles, and that they may be a sign of pneumonia.
C) vesicular breath sounds.
D) fine wheezes.

A patient has been admitted to the emergency department for a suspected drug overdose. His respirations are shallow, with an irregular pattern, with a rate of 12 per minute. The nurse interprets this respiration pattern as which of the following?
A) Bradypnea
B) Cheyne-Stokes respirations
C) Hypoventilation
D) Chronic obstructive breathing

A patient with pleuritis has been admitted to the hospital and complains of pain with breathing. What other key assessment finding would the nurse expect to find upon auscultation?
A) Stridor
B) Friction rub
C) Crackles
D) Wheezing

How do you describe normal tactile fremitus?

What is a positive tactile fremitus test?

How does the nurse assess for tactile fremitus in a patient?

What are three factors that affect the normal intensity of tactile fremitus?