Palpation is the assessment technique used to find which abnormal findings? (Select all that apply.)

Stridor

Finger clubbing

Tracheal deviation

Limited chest expansion

Increased tactile fremitus

Use of accessory muscles

Answer and Explanation

Correct Answer : B,C,D,E

Palpation is used to assess finger clubbing, tracheal deviation, limited chest expansion, and increased tactile fremitus. These findings provide important information about underlying respiratory or cardiac abnormalities and help identify structural or functional changes in the lungs and thorax.

Rationale for correct answers:
2. Finger clubbing. Palpation of the nail beds can confirm the presence of clubbing, which indicates chronic hypoxemia associated with conditions such as lung cancer, bronchiectasis, or chronic obstructive pulmonary disease (COPD).
3. Tracheal deviation. By gently palpating the trachea at the suprasternal notch, the nurse can detect deviation from the midline, which may occur with pneumothorax, pleural effusion, or atelectasis.
4. Limited chest expansion. Placing hands on the posterior chest wall allows the nurse to assess for symmetry and depth of chest movement during respiration. Decreased or asymmetric expansion may indicate lung collapse, pleural effusion, or pneumonia.
5. Increased tactile fremitus. Palpation while the patient repeats a phrase (e.g., “ninety-nine”) can detect vibration transmission through the chest wall. Increased fremitus suggests lung consolidation, as in pneumonia, where sound waves travel more efficiently through dense tissue.

Rationale for incorrect answers:
1. Stridor. Stridor is a high-pitched inspiratory sound heard primarily with auscultation, not palpation.
6. Use of accessory muscles. The use of neck and shoulder muscles during breathing is observed visually, not palpated.

Take-home points:

Palpation assesses structural alignment, symmetry, movement, and tactile vibrations of the chest.
Key abnormal findings include tracheal shift, limited expansion, fremitus changes, and clubbing.
Auscultation and inspection are used for detecting breath sounds and muscle use, not palpation.
Combined use of inspection, palpation, percussion, and auscultation ensures a complete respiratory assessment.

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Correct Answer is A

Explanation

To promote the release of surfactant, the nurse should encourage the patient to take deep breaths. Deep inspiration stretches the alveoli, stimulating type II alveolar cells to produce and secrete surfactant, which reduces surface tension and prevents alveolar collapse, thereby improving gas exchange and lung compliance.

Rationale for correct answer:
1. Take deep breaths. Deep breathing increases alveolar expansion, which triggers the production and release of pulmonary surfactant. Surfactant coats the alveolar surfaces, reducing surface tension and helping to keep alveoli open during exhalation. This mechanism is especially important for preventing atelectasis (alveolar collapse) and maintaining effective ventilation-perfusion balance.

Rationale for incorrect answers:
2. Cough five times per hour to prevent alveolar collapse. While coughing helps clear secretions and promote airway patency, it does not directly stimulate surfactant production. Deep breathing, not coughing, is the physiologic action that enhances surfactant release by expanding the alveoli.
3. Decrease fluid intake to reduce fluid accumulation in the alveoli. Limiting fluid intake does not influence surfactant production and could even lead to dehydration, thickened secretions, and impaired airway clearance. Surfactant release depends on alveolar expansion, not fluid restriction.
4. Sit with head of bed elevated to promote air movement through the pores of Kohn. Elevating the head of the bed aids ventilation but does not directly stimulate surfactant release. The pores of Kohn allow for collateral air movement between alveoli, but this process is not affected by patient positioning alone.

Take-home points:

Deep breathing enhances surfactant release, maintaining alveolar stability and improving oxygenation.
Coughing and positioning aid airway clearance but do not replace the benefits of alveolar expansion.
Encouraging incentive spirometry or deep breathing exercises is vital for preventing atelectasis in postoperative and immobile patients.

A. “I may feel some pressure at the site.” B. “I may have bleeding at the site following the procedure.” C. “I will be able to go to the bathroom when I return from the test.” D. “I will sense a warm, flushed feeling and an urge to cough when the dye is injected.”

Correct Answer is ["A","B","D"]

Explanation

A client who understands the pulmonary angiography procedure recognizes that pressure and mild bleeding can occur at the catheter insertion site and that a warm, flushed feeling and urge to cough may be experienced when the contrast dye is injected. These are expected responses and indicate an accurate understanding of the procedure and its sensations.

Rationale for correct answers:
1. “I may feel some pressure at the site.” During pulmonary angiography, a catheter is inserted—usually into the femoral vein—and guided into the pulmonary artery. The client may feel mild pressure or discomfort at the insertion site, which is normal and indicates proper procedural awareness.

2. “I may have bleeding at the site following the procedure.” After the procedure, minor bleeding or oozing at the insertion site can occur due to vascular puncture. The nurse must apply pressure and monitor the site for hematoma formation. Recognizing this possibility demonstrates that the client understands a potential post-procedure concern.

4. “I will sense a warm, flushed feeling and an urge to cough when the dye is injected.” The contrast dye used during angiography often causes transient sensations such as warmth, flushing, or a brief urge to cough. These are expected physiological reactions to the contrast medium and are not harmful. The client’s acknowledgment of this indicates appropriate preparation and understanding.

Rationale for incorrect answer:
3. “I will be able to go to the bathroom when I return from the test.” After pulmonary angiography, the client is usually placed on bed rest for several hours to prevent bleeding from the catheter insertion site. Movement, including getting up to use the bathroom, is restricted until the insertion site is stable and vital signs are normal. This statement demonstrates a misunderstanding of post-procedure care.

Take-home points:

Pressure, minor bleeding, and warmth from dye injection are normal experiences during pulmonary angiography.
Clients should remain on bed rest after the procedure to prevent bleeding at the insertion site.
Educating the client on expected sensations and post-procedure precautions promotes comfort, safety, and cooperation.

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Palpation is the assessment technique used to find which abnormal findings? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

To promote the release of surfactant, the nurse encourages the patient to:

Correct Answer is A

Explanation

The nurse is giving instructions to a client having pulmonary angiography. Which of the following statements is the best evidence that the client understands what will take place during the diagnostic procedure? (Select all that apply.)

Correct Answer is ["A","B","D"]

Explanation

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