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NUR 216 Exam 3 With complete solution | Newest 100% verified correct
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NUR 216 Exam 3 With complete solution | Newest 100% verified correct
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NUR 216 Exam 3 With complete solution| Newest 100% verified correct
II II II II
Inspect and auscultate anterior chest
II II II II II II II
Assess with the client sitting, lying, or standing
II II II II II
Inspect and auscultate the anterior chest
II II II II II II II II
Assess for shape and symmetry of the chest wall
II II II II
Identify tachypnea, bradypnea, and hypoventilation
II II
Vertical chest landmarks
II II II II II II II II II II II
Anterior thorax- along the midclavicular lines, bilaterally, asses for accessory muscle use
II II II II II II II II II II II II II II
Maximize sounds by-Have the client take deep breaths with an open mouth each time you
II II II
move the stethoscope
II II II II II
Place diaphragm directly on the skin
II II
Vertical chest landmarks II II II II II II II
Midsternal line- through the center of the sternum II II II II II II II
Midclavicular line- through the midpoint of the clavicle
II II II II II II II II
Anterior axillary line- through the apex of the axillae
II II II II II II II
Posterior axillary line- through the posterior axillary fold
II II II II II II II II II II II
Right and left scapular lines- through the inferior angle of the scapula
II II II II II II
Vertebral line-along the center of the spine
II II II II
Inspect and auscultate posterior chest
II II II II II II II
Identify shape and symmetry of the chest wall
Retractions
II II II II II
Posterior thorax while sitting or standing
II II II
Percussion and auscultation sites
II II II II II II II II
Between the scapula and the vertebrae of the back,
II II II II II II II II II
below the scapula along the right and left scapula line
II II
Ventilation vs diffusion II II II II II II II II
Ventilation- exchange of O2 and CO2 in the lungs
II II II II II II II II II II II II II
Diffusion- exchange of O2 and CO2 between alveoli and RBC, hypoxemia if not enough
II II
Overall chest inspection
II II II II II II II II II II II II II
Shape- the anteroposterior diameter is one third to one half of the transverse diam
II II II II II II II II II II II II II
Symmetry- the chest is symmetric with no deformities of the ribs, sternum, scapula or
, II II II II II II
vertebrae, and equal movements during respiration
II II II
ICS- no excessive retractions
II
Respiratory effort II II
Respiratory effort evaluation II II II II
Between 12-20 breaths per min
II II II II II II
Character of breathing- diaphragmatic, abdominal and thoracic
II II II
Use of accessory muscle
II II
Chest wall expansion
II II II II
Depth of respirations-unlabored, quiet breathing
II II II II II II II
Cough- if productive, not the color and consistency II
Trachea- midline II
Thorax percussion II II II II II
Compare both sides to each other
II
Unexpected findings II II II II II II II II II II II II
Dullness- in fluid or solid tissue, this can indicate pneumonia or a tumor II II II II II II II II II II II
Hyperresonance- in the presence of air, this can indicate pneumothorax or emphysema II II II
Respiratory Auscultation expected sounds II II II
Eupnea, bronchial, bronchovesicular, vesicular II II II
respiratory auscultation unexpected sounds II II II II II II II
crackles/rales, wheezes, ronchi, pleural friction rub, stridor, apnea
eupnea II
normal breathing
bronchial II II II II II II II II II II II
loud, high pitched, hollow quality, expiration longer than inspiration over the trachea
Bronchovesicular II II II II II II II II II II II
medium pitch, blowing sounds and intensity with equal inspiration and expiration times
II II II II
over the larger airways
Vesicular II II II II II II II II II II
soft, low-pitched breezy sounds,inspiration three times longer than expiration over most
II II II II II
peripheral areas of the lungs II
crackles (rales)
II II II II II II II II II II II II II II II
fine to coarse bubbly sounds (not cleared with coughing) as air passes through fluid or re-
II II II
expands collapses small airways
wheezes II II II II II II II II II II
high-pitched whistling musical sounds as air passes through narrowed or obstructed
II II II II II
airways, usually louder on expiration
ronchi
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