Thorax/Lung
Which of these statements is true regarding the vertebra prominens?
A. It is the spinous process of C7.
B. It is nonpalpable in most individuals.
C. It is opposite the interior border of the scapula.
D. It is located next to the manubrium of the sternum.
ANS: A
The spinous process of C7 is the vertebra prominens and is the most prominent bony spur protruding at the base of the neck. Counting ribs and intercostal spaces on the posterior thorax is difficult because of the muscles and soft tissue. The vertebra prominens is easier to identify and is used as a starting point in counting thoracic processes and identifying landmarks on the posterior chest. The vertebra prominens is not opposite the interior border of the scapula or next to the manubrium of the sternum. Instead, the vertebra prominens is the spinous process of C7. It is the most prominent bony spur protruding at the base of the neck, thus, it is easy to identify and palpate. Because counting ribs and intercostal spaces on the posterior thorax is difficult due to the number of muscles and soft tissue, the vertebra prominens is used as a starting point in counting thoracic processes and identifying landmarks on the posterior chest.
What is the sac that surrounds and protects the heart is called?
A. Myocardium
B. Pericardium
C. Endocardium
D. Pleural space
ANS: B
The pericardium is a tough, fibrous double-walled sac that surrounds and protects the heart. It has two layers that contain a few milliliters of serous pericardial fluid. The myocardium is the muscular wall of the heart. The endocardium is the thin layer of endothelial tissue that lines the inner surface of the heart chambers and valves. The pleural space is the space between the visceral and parietal pleura of each lung. The sac that surrounds and protects the heart is the pericardium.
During an assessment, the nurse notices that a patient’s left arm is swollen from the shoulder down to the fingers, with non-pitting brawny edema. The right arm is normal. The patient had a left-sided mastectomy 1 year ago. Based on these findings, what does the nurse suspect?
A. Lymphedema
B. Venous stasis
C. Arteriosclerosis
D. Deep-vein thrombosis
ANS: A
Lymphedema after breast cancer causes unilateral swelling and non-pitting brawny edema, with overlying skin indurated. It is caused by the removal of lymph nodes with breast surgery or damage to lymph nodes and channels with radiation therapy for breast cancer, and lymphedema can impede drainage of lymph. The other responses are not correct. Venous stasis is the pooling of blood in the legs, not in the arms. Deep vein thrombosis is the development of a thrombus, or clot, in a deep vein, most commonly in the legs, not the arms. Arteriosclerosis is increased rigidity of the peripheral blood vessels that occurs with aging. The symptoms this patient is experiencing are from lymphedema.
During an assessment of a 68-year-old man with a recent onset of right-sided weakness, the nurse hears a blowing, swishing sound with the bell of the stethoscope over the left carotid artery. What does this finding indicate?
A. Valvular disorder
B. Blood flow turbulence
C. Fluid volume overload
D. Ventricular hypertrophy
ANS: B
A blowing, swishing sound heard over the carotid artery is a bruit. This sound indicates blood flow turbulence; normally none is present. It does not indicate a valvular disorder (that would be heard when auscultating the heart not the carotid artery), fluid volume overload or ventricular hypertrophy.
What should the nurse do when assessing the carotid arteries of an older patient with cardiovascular disease?
A. Palpate the artery in the upper one-third of the neck.
B. Simultaneously palpate both arteries to compare amplitude.
C. Listen with the bell of the stethoscope to assess for bruits.
D. Instruct the patient to take slow deep breaths during auscultation.
ANS: C
If cardiovascular disease is suspected, then the nurse should auscultate each carotid artery for the presence of a bruit. The nurse should avoid compressing the artery, which could create an artificial bruit and compromise circulation if the carotid artery is already narrowed by atherosclerosis. Excessive pressure on the carotid sinus area high in the neck should be avoided, and excessive vagal stimulation could slow down the heart rate, especially in older adults. Palpating only one carotid artery at a time will avoid compromising arterial blood to the brain. The carotid pulse should be palpated medial to the sternomastoid muscle near the base of the neck (not the upper third).
When performing a respiratory assessment on a patient, the nurse notices a costal angle of approximately 90 degrees. What should the nurse recognize about this finding?
A. Observed 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.
ANS: C
The right and left costal margins form an angle where they meet at the xiphoid process. Usually, this angle is 90 degrees or less. The angle increases when the rib cage is chronically overinflated (barrel chest), as in emphysema.This is a normal finding and is not associated with kyphosis or indicative of pectus excavatum.
When listening to heart sounds, which valve closures are heard best at the base of the heart?
A. Aortic and pulmonic
B. Mitral and pulmonic
C. Mitral and tricuspid
D. Tricuspid and aortic
ANS: A
The second heart sound (S2) occurs with the closure of the semilunar (aortic and pulmonic) valves and signals the end of systole. Although it is heard over all the precordium, the S2 is loudest at the base of the heart.
The nurse is preparing to assess the dorsalis pedis artery. Where is the correct location for palpation?
A. Behind the knee
B. Over the lateral malleolus
C. In the groove behind the medial malleolus
D. Lateral to the extensor tendon of the great toe
ANS: D
The dorsalis pedis artery is located on the dorsum of the foot. The nurse should palpate just lateral to and parallel with the extensor tendon of the big toe. The popliteal artery is palpated behind the knee. The posterior tibial pulse is palpated in the groove between the malleolus and the Achilles tendon. No pulse is palpated at the lateral malleolus.
What should the nurse do when assessing the carotid arteries of an older patient with cardiovascular disease?
A. Palpate the artery in the upper one-third of the neck.
B. Simultaneously palpate both arteries to compare amplitude.
C. Listen with the bell of the stethoscope to assess for bruits.
D. Instruct the patient to take slow deep breaths during auscultation.
ANS: C
If cardiovascular disease is suspected, then the nurse should auscultate each carotid artery for the presence of a bruit. The nurse should avoid compressing the artery, which could create an artificial bruit and compromise circulation if the carotid artery is already narrowed by atherosclerosis. Excessive pressure on the carotid sinus area high in the neck should be avoided, and excessive vagal stimulation could slow down the heart rate, especially in older adults. Palpating only one carotid artery at a time will avoid compromising arterial blood to the brain. The carotid pulse should be palpated medial to the sternomastoid muscle near the base of the neck (not the upper third).
What component of the conduction system is referred to as the pacemaker of the heart?
A. Bundle of His
B. Bundle branches
C. Sinoatrial (SA) node
D. Atrioventricular (AV) node
ANS: C
Specialized cells in the SA node near the superior vena cava initiate an electrical impulse. Because the SA node has an intrinsic rhythm, it is called the pacemaker of the heart. After the electrical impulse is initiated, it travels across the atria to the AV node where it is delayed slightly so the atria have time to contract before the ventricles are stimulated. Then the impulse travels to the bundle of His, the right and left bundle branches, and then through the ventricles.
When assessing a patient’s lungs, what should the nurse recall about the left lung?
A. Consists of two lobes.
B. Is divided by the horizontal fissure.
C. Primarily consists of an upper lobe on the posterior chest.
D. Is shorter than the right lung because of the underlying stomach.
ANS: A
The left lung has two lobes and is longer and narrower than the right lung. It is narrower than the right lung because the heart bulges to the left. The right lung has three lobes and is shorter than the left lung because of the underlying liver. The posterior chest is almost all lower lobes.
The direction of blood flow through the heart is best described by which of these?
A. Vena cava → right atrium → right ventricle → lungs → pulmonary artery → left atrium → left ventricle
B. Right atrium → right ventricle → pulmonary artery → lungs → pulmonary vein → left atrium → left ventricle
C. Aorta → right atrium → right ventricle → lungs → pulmonary vein → left atrium → left ventricle → vena cava
D. Right atrium → right ventricle → pulmonary vein → lungs → pulmonary artery → left atrium → left ventricle
ANS: B
Returning blood from the body empties into the right atrium and flows into the right ventricle and then goes to the lungs through the pulmonary artery. The lungs oxygenate the blood, and it is then returned to the left atrium through the pulmonary vein. The blood goes from there to the left ventricle and then out to the body through the aorta.
Which vein(s) is(are) responsible for most of the venous return in the arm?
A. Deep
B. Ulnar
C. Subclavian
D. Superficial
ANS: D
The superficial veins of the arms are in the subcutaneous tissue and are responsible for most of the venous return.
When the nurse is auscultating the carotid artery for bruits, which of these statements reflects the correct technique?
A. While listening with the bell of the stethoscope, the patient is asked to take a deep breath and hold it.
B. While auscultating one side with the bell of the stethoscope, the carotid artery is palpated on the other side to check pulsations.
C. While lightly applying the bell of the stethoscope over the carotid artery and listening, the patient is asked to take a breath, exhale, and briefly hold it.
D. While firmly placing the bell of the stethoscope over the carotid artery and listening, the patient is asked to take a breath, exhale, and briefly hold it.
ANS: C
The correct technique for auscultating the carotid artery for bruits involves the nurse lightly applying the bell of the stethoscope over the carotid artery at three levels. While listening, the nurse asks the patient take a breath, exhale, and briefly hold it. Holding the breath on inhalation will also tense the levator scapulae muscles, which makes it hard to hear the carotid arteries. Examining only one carotid artery at a time will avoid compromising arterial blood flow to the brain. Pressure over the carotid sinus, which may lead to decreased heart rate, decreased blood pressure, and cerebral ischemia with syncope, should be avoided.
When assessing a patient’s pulse, the nurse notes that the amplitude is weaker during inspiration and stronger during expiration. When the nurse measures the blood pressure, the reading decreases 20 mm Hg during inspiration and increases with expiration. What do these findings indicate?
A. Pulsus alternans
B. Pulsus bisferiens
C. Pulsus bigeminus
D. Pulsus paradoxus
ANS: D
In pulsus paradoxus, beats have weaker amplitude with inspiration and stronger amplitude with expiration and is best determined during blood pressure measurement; reading decreases (>10 mm Hg) during inspiration and increases with expiration. In pulsus alternans, the rhythm is regular, but force varies, with alternating beats of large and small amplitude. In pulsus bisferiens, each pulse has two strong systolic peaks with a dip in between and is best assessed at the carotid artery. In pulsus bigeminus, the beats are coupled, every other beat comes early, or normal beat is followed by a premature beat. The force of the premature beat is decreased because of shortened cardiac filling time. This patient’s weaker amplitude during inspiration and stronger during expiration is pulsus paradoxus.
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. What does this finding indicate?
A. Fine wheezes
B. Vesicular breath sounds
C. Fine crackles and may be a sign of pneumonia
D. Atelectatic crackles that do not have a pathologic cause
ANS: D
One type of adventitious sound, atelectatic crackles, does not have a pathologic cause. They are short, popping, crackling sounds that sound similar to fine crackles but do not last beyond a few breaths. When sections of alveoli are not fully aerated (as in people who are asleep or in older adults), they deflate slightly and accumulate secretions. Crackles are heard when these sections are expanded by a few deep breaths. Atelectatic crackles are heard only in the periphery, usually in dependent portions of the lungs, and disappear after the first few breaths or after a cough. Although crackles can be a sign of pneumonia, this patient’s crackles resolved after a few deep breaths which would not happen if there was pneumonia.
Which of these statements describes the closure of the valves in a normal cardiac cycle?
A. The pulmonic valve closes slightly before the aortic valve.
B. The aortic valve closes slightly before the tricuspid valve.
C. Both the tricuspid and pulmonic valves close at the same time.
D. The tricuspid valve closes slightly later than the mitral valve.
ANS: D
Events occur just slightly later in the right side of the heart because of the route of myocardial depolarization. As a result, two distinct components to each of the heart sounds exist, and sometimes they can be heard separately. In the first heart sound, the mitral component (M1) closes just before the tricuspid component (T1).
The nurse is teaching a review class on the lymphatic system. Which statement by a class participant indicates correct understanding of the material?
A. “Lymph flow is propelled by the contraction of the heart.”
B. “The flow of lymph is slow, compared with that of the blood.”
C. “One of the functions of the lymph is to absorb lipids from the biliary tract.”
D. “Lymph vessels have no valves; therefore, lymph fluid flows freely from the tissue spaces into the bloodstream.”
ANS: B
The flow of lymph is slow, compared with flow of the blood. Lymph flow is not propelled by the heart but rather by contracting skeletal muscles, pressure changes secondary to breathing, and contraction of the vessel walls. Lymph does not absorb lipids from the biliary tract. The vessels do have valves; therefore, flow is one way from the tissue spaces to the bloodstream.
The nurse is assessing a patient with possible cardiomyopathy and assesses the hepatojugular reflux. If heart failure is present, then the nurse should recognize which finding while pushing on the right upper quadrant of the patient’s abdomen, just below the rib cage?
A. The jugular veins will not be detected during this maneuver.
B. The jugular veins will remain elevated as long as pressure on the abdomen is maintained.
C. An impulse will be visible at the fourth or fifth intercostal space at or inside the midclavicular line.
D. The jugular veins will rise for a few seconds and then recede back to the previous level if the heart is properly working.
ANS: B
When performing hepatojugular reflux, the jugular veins will rise for a few seconds and then recede back to the previous level if the heart is able to pump the additional volume created by the pushing. However, with heart failure, the jugular veins remain elevated as long as pressure on the abdomen is maintained.
When listening to heart sounds, which valve closures are heard best at the base of the heart?
A. Aortic and pulmonic
B. Mitral and pulmonic
C. Mitral and tricuspid
D. Tricuspid and aortic
ANS: A
The second heart sound (S2) occurs with the closure of the semilunar (aortic and pulmonic) valves and signals the end of systole. Although it is heard over all the precordium, the S2 is loudest at the base of the heart.
The nurse is assessing voice sounds during a respiratory assessment. Which of these findings indicates a normal assessment? (Select all that apply).
A. As the patient says a long “ee-ee-ee” sound, the examiner hears a long “aaaaaa” sound.
B. As the patient says a long “ee-ee-ee” sound, the examiner also hears a long “ee-ee-ee” sound.
C. As the patient repeatedly says “ninety-nine,” the examiner clearly hears the words “ninety-nine.”
D. Voice sounds are faint, muffled, and almost inaudible when the patient whispers “one, two, three” in a very soft voice.
E. When the patient speaks in a normal voice, the examiner can hear a sound but cannot exactly distinguish what is being said.
ANS: B, D, E
As a patient repeatedly says “ninety-nine,” normally the examiner hears voice sounds but cannot distinguish what is being said. If a clear “ninety-nine” is auscultated, then it could indicate increased lung density, which enhances the transmission of voice sounds, which is a measure of bronchophony. When a patient says a long “ee-ee-ee” sound, normally the examiner also hears a long “ee-ee-ee” sound through auscultation, which is a measure of egophony. If the examiner hears a long “aaaaaa” sound instead, this sound could indicate areas of consolidation or compression. With whispered pectoriloquy, as when a patient whispers a phrase such as “one-two-three,” the normal response when auscultating voice sounds is to hear sounds that are faint, muffled, and almost inaudible. If the examiner clearly hears the whispered voice, as if the patient is speaking through the stethoscope, then consolidation of the lung fields may exist.
The nurse is preparing to auscultate for heart sounds. Which technique is correct?
A. Listening for all possible sounds at a time at each specified area.
B. Listening to the sounds at the aortic, tricuspid, pulmonic, and mitral areas.
C. Listening to the sounds only at the site where the apical pulse is felt to be the strongest.
D. Listening by inching the stethoscope in a rough Z pattern, from the base of the heart across and down, then over to the apex.
ANS: D
Auscultation of breath sounds should not be limited to only four locations. Sounds produced by the valves may be heard all over the precordium. The stethoscope should be inched in a rough Z pattern from the base of the heart across and down, then over to the apex; or, starting at the apex, it should be slowly worked up. Listening selectively to one sound at a time is best.
A patient has hard, non-pitting edema of the left lower leg and ankle. The right leg has no edema. When interpreting these findings, what should the nurse recall?
A. Alterations in arterial function will cause edema.
B. Nonpitting, hard edema occurs with lymphatic obstruction.
C. Phlebitis of a superficial vein will cause bilateral edema.
D. Long-standing arterial obstruction will cause pitting edema.
ANS: B
Unilateral edema occurs with occlusion of a deep vein or with unilateral lymphatic obstruction and causes edema that is nonpitting and feels hard to the touch (brawny edema). Alterations in arterial function or long-standing arterial obstruction do not cause lower leg edema nor does phlebitis of a superficial vein. Instead, lower leg edema is caused by problems with the heart or deep veins, lymphatic system, or kidneys.
The findings from an assessment of a 70-year-old patient with swelling in his ankles include jugular venous pulsations 5 cm above the sternal angle when the head of his bed is elevated 45 degrees. What does this finding indicate?
A. Decreased fluid volume
B. Increased cardiac output
C. Narrowing of jugular veins
D. Elevated pressure r/t heart failure
ANS: D
Because no cardiac valve exists to separate the superior vena cava from the right atrium, the jugular veins give information about the activity on the right side of the heart. They reflect filling pressures and volume changes. Normal jugular venous pulsation is 2 cm or less above the sternal angle. Elevated pressure is more than 3 cm above the sternal angle at 45 degrees and occurs with heart failure.
During a visit to the clinic, a woman in her seventh month of pregnancy states that her legs feel “heavy in the calf” and that she often has foot cramps at night. The nurse notices that the patient has dilated, tortuous veins apparent in her lower legs. Which condition is reflected by these findings?
A. Lymphedema
B. Varicose veins
C. Raynaud phenomenon
D. Deep vein thrombophlebitis
ANS: B
Superficial varicose veins are caused by incompetent distant valves in the veins, which results in the reflux of blood, producing dilated, tortuous veins. Varicose veins are more common in women, and pregnancy can also be a cause. Symptoms include aching, heaviness in the calf, easy fatigability, and night leg or foot cramps. Dilated, tortuous veins are observed on assessment. Lymphedema is the accumulation of protein-rich fluid in the interstitial spaces in the arm, not the leg. Raynaud phenomenon presents as episodes of abrupt, progressive tricolor change of the fingers in response to cold, vibration, or stress. The symptoms of deep vein thrombophlebitis are warmth, swelling, redness, tender to palpation, and may have dependent cyanosis. This patient is experiencing superficial varicose veins which are caused by incompetent distant valves in the veins, which results in the reflux of blood, producing dilated, tortuous veins.