The nurse is doing an assessment of an adult client and noticed unequal chest expansion. The nurse recognizes that unequal chest expansion occurs:
When part of the lung is obstructed or collapsed
When bulging of the intercostal spaces is present
In an obese patient
When accessory muscles are used to augment respiratory effort
The Correct Answer is A
A. When part of the lung is obstructed or collapsed: This statement is accurate. Unequal chest expansion can occur when part of the lung is obstructed or collapsed, preventing the affected area from expanding normally during inhalation.
B. When bulging of the intercostal spaces is present: This statement is not accurate. Unequal chest expansion typically refers to decreased expansion on one side, not bulging of intercostal spaces.
C. In an obese patient: This statement is not accurate. Obesity can affect breathing patterns and lung function, but it is not the primary cause of unequal chest expansion.
D. When accessory muscles are used to augment respiratory effort: This statement is not accurate. The use of accessory muscles to augment respiratory effort can be a sign of respiratory distress, but it doesn't directly cause unequal chest expansion. Unequal expansion is more indicative of specific lung conditions or issues with lung mechanics.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Bronchovesicular breath sounds and normal in that location:
Bronchovesicular breath sounds are medium-pitched sounds heard over the major bronchi and are usually equal on inspiration and expiration. They are typically heard in the 1st and 2nd intercostal spaces anteriorly and between the scapulae posteriorly. While they might be normal in certain locations, hearing them over peripheral lung fields might indicate an abnormality.
B. Normally auscultated over the trachea:
This statement doesn't specify a particular type of breath sound. Tracheal breath sounds are harsh and relatively high-pitched, heard directly over the trachea. They are normal over the trachea but are not normally heard in the lung periphery.
C. Vesicular breath sounds and normal in that location:
Vesicular breath sounds are low-pitched, soft sounds heard over most of the lungs during inspiration. They are longer on inspiration than expiration and are considered normal breath sounds heard in the peripheral lung fields. Hearing vesicular sounds in the posterior lower lobes is typical and indicates normal lung function.
D. Bronchial breath sounds and normal in that location:
Bronchial breath sounds are high-pitched and loud, heard primarily over the trachea and larynx. If heard in the peripheral lung fields, especially in the lower lobes, it can suggest an abnormality such as consolidation or compression of lung tissue.
Correct Answer is C
Explanation
A. Fifth intercostal space, left of the midclavicular line: This placement is used to auscultate the mitral valve, which is best heard at the apex of the heart. The mitral valve sounds are typically heard around the fifth intercostal space, midclavicular line.
B. Left lower sternal border: This placement is used to auscultate the tricuspid valve, which is best heard at the lower left sternal border.
C. Second left intercostal space: This is the correct placement for auscultating the pulmonic valve. The pulmonic valve sounds are best heard at the second left intercostal space, which is close to the upper left sternal border.
D. Second right intercostal space: This placement is used to auscultate the aortic valve, which is best heard at the second right intercostal space, close to the upper right sternal border.
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