Exam (elaborations)
NUR 216 EXAM 3 QUESTIONS WITH CORRECT ANSWERS
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NUR 216 EXAM 3 QUESTIONS WITH CORRECT ANSWERS
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NUR 216 EXAM 3 QUESTIONS WITH CORRECT ANSWERS1.Inspect and auscultate anterior chest: Assess with the client sitting,
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lying, or standing
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Inspect and auscultate the anterior chest
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Assess for shape and symmetry of the chest wall
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Identify tachypnea, bradypnea, and
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chypoventilation Vertical chest landmarks c c c
Anterior thorax- along the midclavicular lines, bilaterally, asses for
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accessory muscle use
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Maximize sounds by-Have the client take deep breaths with an open
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mouth each time you move the stethoscope
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Place diaphragm directly on the skin
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2.Vertical chest landmarks: Midsternal line- through the center of the
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sternum Midclavicular line- through the midpoint of the clavicle
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Anterior axillary line- through the apex of the
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axillae Posterior axillary line- through the
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posterior axillary fold
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Right and left scapular lines- through the inferior angle of the scapula
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Vertebral line-along the center of the spine
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3.Inspect and auscultate posterior chest: Identify shape and symmetry
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of the chest wall
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Retractions
Posterior thorax while sitting or c c c c
c standing Percussion and c c
c auscultation sites c
Between the scapula and the vertebrae of the
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back, below the scapula along the right and left
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scapula line
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4.Ventilation vs diffusion: Ventilation- exchange of O2 and CO2 in the
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, c lungs
Diffusion- exchange of O2 and CO2 between alveoli and RBC, hypoxemia i
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not enough
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5.Overall chest inspection: Shape- the anteroposterior diameter is one
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third to one half of the transverse diam
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, Symmetry- the chest is symmetric with no deformities of the ribs,
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sternum, scapula or vertebrae, and equal movements during respiration
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ICS- no excessive retractions
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Respiratory effort
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6.Respiratory effort evaluation: Between 12-20 breaths per c c c c c c
c min Character of breathing- diaphragmatic, abdominal
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c and thoracic Use of accessory muscle
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Chest wall expansion
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Depth of respirations-unlabored, quiet breathing
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Cough- if productive, not the color and
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consistency Trachea- midline
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7.Thorax percussion: Compare both sides to each other
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Unexpected findings c
Dullness- in fluid or solid tissue, this can indicate pneumonia or a tumor
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Hyperresonance- in the presence of air, this can indicate pneumothorax
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or emphy- sema
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8.Respiratory Auscultation expected sounds: Eupnea, bronchial, c c c c c
bronchovesic- ular, vesicular
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9.respiratory auscultation unexpected sounds: crackles/rales, wheezes,
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ronchi, pleural friction rub, stridor, apnea
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10.eupnea: normal breathing c c
11.bronchial: loud, high pitched, hollow quality, expiration longer than
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inspiration over the trachea
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12.Bronchovesicular: medium pitch, blowing sounds and intensity with c c c c c c c
equal in- spiration and expiration times over the larger airways
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13.Vesicular: soft, low-pitched breezy sounds,inspiration three times
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longer than expiration over most peripheral areas of the lungs
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14.crackles (rales): fine to coarse bubbly sounds (not cleared with
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coughing) as air passes through fluid or re-expands collapses small
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airways
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