Inspection
A 34-year-old patient is resting in bed. Respirations are 16/min, quiet, and effortless. The chest rises evenly on both sides.
Question: Which finding should the nurse document?
Normal respiratory pattern
Rationale: These are all expected findings for an adult
The nurse places both hands on the posterior thorax at approximately T9–T10 and asks the patient to inhale deeply. Which assessment is the nurse performing?
thoracic expansion
Rationale: This is the procedure steps
The nurse is auscultation breath sounds over the upper center area of the posterior thorax between the vertebrae between the scapulae
Question: Which breath sounds should the nurse hear?
bronchovesicular
Rationale: think bronchus which is near the neck...these sounds should also be in line with the bronchus.
The nurse percusses the posterior lung fields of a healthy adult with no respiratory symptoms.
Question: Which tone should the nurse expect?
resonance
Rationale: This is a normal sound
A patient reports episodic chest tightness and dyspnea. The nurse notes tachypnea, prolonged expiration, expiratory wheezing, and accessory-muscle use.
Question: Which condition is most consistent with these findings?
asthma
Rationale: expiratory wheeze is a big indication of asthma exacerbation
During a breast examination, the nurse carefully examines the area of the breast tissue that extends toward the axila.
Which anatomical structure is the nurse assessing?
Tail of Spence
Rationale: Tail of spence is the extension of the breast into the upper, outer quadrant
The nurse assesses a patient with asthma and notes RR 30/min, expiratory wheezing, accessory-muscle use, and SpO₂ 90%.
Question: The nurse is collecting and identifying relevant findings. Which Clinical Judgment Model step is this?
recognize cues
Rationale: Nurse is collecting her assessment data and reviewing findings
A patient with chronic lung disease is thin with AP ration of 1:1.
Question: Which chest configuration should the nurse identify?
Barrel Chest
Rationale: Normal chest AP is 1:2. 1:1 would be associated with COPD or Emphysema
A patient with fever and productive cough is diagnosed with pneumonia. The nurse places both hands on the chest while the patient repeats “ninety-nine.”
Question: Which assessment finding would the nurse anticipate?
Increased fremitus
Rationale: When sound waves hit fluid they increase vibration.
A patient with heart failure develops dyspnea and fine popping sounds at both lung bases during inspiration. The sounds do not clear with coughing.
Question: Which adventitious sound should the nurse document?
crackles
Rationale: Fluid causes crackles and can sound like rice crispy, velcro, hair rubbing
A patient with fever and productive cough has consolidation in the right lower lobe.
Question: Which percussion tone should the nurse expect over this area?
dullness
Rationale: Fluid/pus blocks sound waves and created dullness
A patient with a long smoking history reports a productive cough that occurs for months at a time. The nurse notes chronic mucus production, dyspnea, afebrile and rhonchi that lessen after coughing.
Question: Which condition should the nurse suspect?
bronchitis
Rationale: Think no fever for this "itis" condition. productive cough.
A patient reports discovreing a new breast mass. The nurse palpates a firm, irregular, poorly mobile mass in the upper outer breast and also identifies non tender axillary lymph nodes.
Which condition is consistent with these symptoms?
Breast malignancy
Rationale: A firm, irregular mass combined with abnormal axillary lymph node findings require further evaluation.
A postoperative patient has shallow respirations, diminished breath sounds at the right base, SpO₂ 89%, and has been avoiding deep breathing because of pain. The nurse considers atelectasis, pneumonia, and opioid-related respiratory depression, then determines which problem is most likely.
Question: Which Clinical Judgment Model step is the nurse performing?
prioritize hypothesis
Rationale: The nurse looks at her cues and prioritized which they believe to be the likely cause
A patient with worsening dyspnea is restless and using the neck and shoulder muscles to breathe. Intercostal retractions are visible.
Question: Which problem should the nurse identify?
Respiratory Distress
Rationale: All symptoms point to a respiratory compromise.
The nurse inspects a patient’s fingernails and notes that the nail-base angle is greater than expected with bulbous enlargement of the fingertips.
Question: Which finding should the nurse document?
clubbing
Rationale: chronic hypoxia can cause clubbing. This is often seen in COPD/Emphysema
A patient develops severe respiratory difficulty and a harsh, high-pitched sound is heard over the upper airway.
Question: Which sound should the nurse identify?
Stridor
Rationale: airway narrowing causes a decreased in air passage
A patient develops sudden unilateral chest pain and dyspnea. The nurse notes absent breath sounds and a very loud, booming percussion tone over the affected side.
Question: Which percussion finding supports a emphysema?
Hyperresonance
Rationale: Air trapping causes a loud boom sound. Think of the really large, overinflated balloon I showed you in class.
A patient reports dyspnea and sharp chest pain that worsens with deep inspiration. The nurse notes decreased fremitus and absent breath sounds over one lower lung field.
Question: Which condition best explains these findings?
Pleural effusion
Rationale: sharp chest pain is a key indicator along with decreased fremitus because of the fluid between the pleural cavity. Breath sounds decreased because of fluid presence
During assessment of an eldery man, the nurse notes bilateral enlargement of breast tissue. The patient has no pain, drainage, skin changes, or palpable masses.
How should the nurse interpret this finding?
Expected gynecomastia in an elderly patient
Rationale: Natural decline in testosterone can cause breast tissue enlargement. This also happens in male teenagers as well.
A patient with an asthma exacerbation receives treatment. The nurse reassesses the patient and compares the current respiratory rate, oxygen saturation, breath sounds, and work of breathing with the findings documented before treatment.
Question: Which Clinical Judgment Model step is the nurse performing?
evaluate outcomes
Rationale: After performing a treatment, the nurse evaluates if it worked
A patient with darkly pigmented skin has increasing shortness of breath. The nurse is concerned about cyanosis.
Question: Which area should the nurse inspect most closely?
Oral Mucosa
Rationale: This is often the easiest place to see cyanosis. The sclera, and fingernails may also e alternative sites, but your book identifies oral mucosa.
A patient with pleural effusion has dyspnea and diminished breath sounds over the left base.
Question: Which tactile fremitus finding should the nurse expect?
Decreased fremitus
Rationale: The layer of fluid in the pleural cavity acts as a barrier that dampens or absorbs the low frequency.
A patient with fever, productive cough, and pleuritic chest pain has vesicular sounds over most lung fields. Over the right lower lobe, the nurse hears loud, high-pitched breath sounds with expiration longer than inspiration.
Question: Which auscultatory finding should the nurse document over the right lower lobe?
Bronchial breath sounds
Rationale: Expiration > than inspiration is brochinal.
Vesicular: inspiration >expiration and soft, normal.
Bronchovesicular: Inspiration=Expiration, moderate pitch.
The nurse percusses from the right lung field downward and notes a change from resonance to dullness.
Question: Which structure has the nurse reached?
liver
Rationale: The liver is a solid organ, and when percussed it is dull. As you move down toward more air or gas filled areas it becomes resonant again.
Following chest trauma, a patient develops dyspnea, hypotension, tachycardia, cold clammy skin, and diminished breath sounds over one lung.
Question: Which condition should the nurse suspect?
Hemothorax
Rationale: hypotension, tachycardia are big indicators of blood loss/shock. Hemo means blood so think hemothorax
During a breast health teaching visit, a 45 year-old patient states "If I examine my breast every month, I can wait until I feel an abnormality to get my mammogram".
What education should the nurse provide to this patient?
Breast self-exams do not replace mammograms. It can help uncover a mass/cyst, but does not replace regular mammography that can pick up non-palpable masses.
A patient receiving opioid analgesia becomes difficult to arouse with a respiratory rate of 8/min and SpO₂ 87%. The nurse stops the opioid infusion, increases oxygen, and notifies the provider.
Question: Which Clinical Judgment Model step is best demonstrated by these nursing interventions?
take action
Rationale: The nurse does something to improve the symptoms. Ex: meds, O2, position change.
An 80-year-old patient has kyphosis and mildly reduced chest expansion. Respirations are unlabored, SpO₂ is 96%, and the patient denies dyspnea.
Question: How should the nurse interpret these findings?
Expected findings of aging
Rationale: Kyphosis can cause changes in the diaphragmatic expansion, therefore impacting chest expansion
A patient with a suspected pneumothorax has severe dyspnea and unilateral absent breath sounds. During palpation, the trachea is shifted away from the affected side.
Question: Which complication should the nurse suspect?
tension pneumothorax
Rationale: Pneumothorax is air that has escaped outside the lungs. That air can rise and deviate the trachea. You may also note crepitus on palpation.
A patient with severe asthma initially has diffuse expiratory wheezing. On reassessment, the wheezing is markedly diminished, but breath sounds are now barely audible bilaterally and the patient is increasingly fatigued.
Question: Which finding should the nurse recognize as most concerning?
decreased breath sounds
A patient with fever and a productive cough has decreased breath sounds over the right lower lobe. The nurse percusses the same area and hears a dull tone.
Question: Which pulmonary change is most consistent with this finding?
consolidation
Rationale: Fluid/pus causes dullness
A patient is 12 hours postoperative after abdominal surgery. The nurse notes shallow respirations, increasing tachypnea, SpO₂ of 89%, diminished breath sounds at the right base, and reduced expansion of the right lower chest. The patient reports incisional pain and has been avoiding deep breathing.
Question: Which postoperative complication should the nurse suspect?
atelectasis
Rationale: Atelectasis is common after surgery when patients are in bed a long time, have pain so shallow breath. This can cause alveoli collapse. Incentive spirometers help.
A patient reports a newly discovered breast change. The nurse notes a firm abnormality in the upper out breast extending towward the axilla.
Which additional area is most important for the nurse to assess because of the location of this finding?
Axillary lymph nodes.
Rationale: Breast tissue extends toward the axilla through the tail of spence, making assessment of the axillary region important when identified in the upper outer quadrant.
A patient presents with dyspnea and pleuritic chest pain. The nurse notes decreased breath sounds, decreased tactile fremitus, and dullness to percussion over the left lower lung field. The nurse links these findings to fluid occupying the pleural space (pleural effusion).
Question: Which Clinical Judgment Model step is the nurse demonstrating?
analyze cues
Rationale: The nurse is looking at the cues to identify any abnormals.