Respiratory A&P
This vertical line begins at the mid-clavicle and extends downward past the nipple to the lower ribs. It is located on both the right and left chest wall.
Midclavicular line (MCL)
State at least one question that pertains to the client's present respiratory health condition.
Do you have any difficulties breathing or problems with your lungs? Different from two months ago?
Are you short of breath or have noisy breathing, cough, or sputum?
Do you have chest pain with inspiration or expiration?
Do you need to sit up to help with breathing?
Do you have difficulty breathing when lying flat in bed?
Do you ever cough up blood
Do you ever have chest tightness?
State the common position a client will sit in if they have chronic obstructive pulmonary disease (COPD).
Tripod positioning: body leaning forard and hands resting on their knees or table. This assists in expiring carbon dioxide.
Client uses: abdominal, intercostal, and neck muscles. Exhale through pursed lips. Difficult talking. Demonstrates increased dyspnea and distress.
What is the technique that is usually done at the advanced practice level or if the nurse is working in an area where x-ray and other advanced imaging is not readily accessible.
Percussion.
Which cranial nerve will the nurse assess when performing a respiratory assessment?
A. Olfactory
B. Optic
C. Oculomotor
D. Abducens
A. Olfactory (CN #1). Nose
Which lung only has two lobes?
Left (has an upper and a lower lobe).
FYI: Left is longer and narrower than right
FYI: Right lung has 3 lobes (upper, middle, lower) and is smaller than the left d/t the liver.
State at least one question that pertains to the client's past respiratory health history.
Do you have a history of respiratory problems (COPD, pneumonia, asthma, anemia, pulmonary emboli)?
A client is appearing anxious or confused. What should the nurse do?
Obtain SpO2 levels (oxygen sat). Should be 95%-100%
Hypoxia clouds level of consciousness.
<90% indicates decreased tissue perfusion.
State the best place to apply the stethoscope to minimize adventitious sounds.
underneath the gown.
A nurse is auscultating the trachea. Which breath sound does the nurse anticipate to auscultate?
A. Vesicular
B. Bronchovesicular
C. Bronchial
D. Tracheal
D. Tracheal. It will be harsh, high pitched.
If aspiration occurs, which lung has the high risk for the objects to enter into?
Right lung: the right main bronchus is shorter, wider, and more vertical.
State at least one question that pertains to the client's family history when it comes to the respiratory assessment.
Does anyone in your immediate family have respiratory problems?
How will cyanosis* appear on a client with darker skin tones?
*late-stage hypoxemia
ashen or dusky blue tone of the oral mucosa or nail beds.
A nurse is auscultating client voice sounds. Which assessment is the nurse performing when the nurse instructs the client to state "99" when the stethoscope is placed.
Bronchophony.
Normal lung tissue, the sound is muffled.
If "99" is loud and distinct, there is consolidation in the area, meaning there is fluid or tissue present in that section of the lung.
A nurse will hear this sound when there is inflammation of the pleura during inspiration and expiration.
A. Crackles.
B. Pleural friction rub.
C. Wheeze.
D. Rhonchi
B. Pleural friction rub. painful, low-pitched, course grating tone like two leather pieces are being rubbed together.
State two accessory muscles.
Neck: trapezius, scalene, sternocleidomastoid
Abdomen: rectus
Chest: pectorals
State at least one question that pertains to the client's behavior (lifestyle) when assessing for respiratory health conditions.
Have you ever been exposed to any type of environmental contaminant?
Do you smoke? Pipes, cigars, cigarettes, vape, marijuana?
Do you smoke or inhale other herbal products or chemical preparations (glue, paint)?
When did you receive your last flu, pneumonia, or COVID vaccine?
State the importance of Schamroth's sign.
Assesses for clubbing, which indicates long-term hypoxia exposure.
A nurse is auscultating client voice sounds. Which assessment is the nurse performing when the nurse instructs the client to state "E" when the stethoscope is placed.
Egophony
Normal lung: it will sound like a long "eeeeee"
Lung consolidation: it will sound like a long "aaaaaay"
When a nurse auscultates this high-pitched crowing sound, it is usually a life-threatening emergency.
A. Wheeze.
B. Crackles.
C. Stridor.
D. Pleural rub.
C. Stridor. Usually heard without a stethoscope. Usually due to upper airway obstruction from inflammation or foreign body. May require emergency trach (by an advanced practitioner or RT)
State the medical name for "regular, even-depth, rhythmic pattern of inspiration and expiration".
Eupnea
Dyspnea = shortness of breath or difficulty breathing.
Orthopnea = difficulty breathing when lying supine
A client wants to remain modest during a respiratory exam. What is the best way to have the client wear the gown.
Place the gown on backward, access one side of the anterior chest at a time.
State the palpable difference between respiratory expansion versus tactile fremitus.
Respiratory expansion = Palm of hands, lower posterior chest, thumbs at T10. While taking a deep breath, your hands will expand away, evenly & smooth, lifting symmetrically outward.
Tactile fremitus = Metacarpophalangeal joints of palm, begin at apex, have client clearly state "99" or "1,2,3"; repeat until at the bases.
A nurse is auscultating client voice sounds. Which assessment is the nurse performing when the nurse instructs the client to whisper "1, 2, 3" when the stethoscope is placed.
Whispered pectoriloquy
Normal lung: faint, almost indistinguishable.
Lung consolidation: clear and loud in that area.
A nurse walks past a room and sees a client experiencing dyspnea and appears to be trying to climb out of bed. What is the nurse's initial priority at this time?
A. Perform hand hygiene upon entering the room.
B. Elevate the head of the bed.
C. Obtain a oxygen sat from the oximeter.
D. Apply oxygen and cough and deep breath.
A. Perform hand hygiene.
Then --elevate HOB, ask the client to take deep breaths, while obtaining an oxygen sat, and then apply oxygen if less than 95% or per facility protocol.