The nurse is observing the respiratory effort of a client, and notes that the client's intercostal spaces are retracting on inspiration. The nurse will assess the client for the presence of which condition(s)? Select All That Apply

Thoracic muscle tenderness

Barrel Chest

Pectus excavatum

Atelectasis

Obstruction

Answer and Explanation

Correct Answer : D,E

A.   Thoracic muscle tenderness is not directly associated with intercostal retraction. Muscle tenderness may occur due to overuse or strain but does not cause the retraction of the intercostal spaces. It is more related to musculoskeletal issues rather than respiratory conditions.
B.   Barrel chest refers to an increased anterior-posterior chest diameter, often seen in chronic obstructive pulmonary disease (COPD) and emphysema. While barrel chest can indicate chronic lung conditions that might cause respiratory distress, it does not directly cause intercostal retraction.
C.   Pectus excavatum, or "funnel chest," is a congenital deformity where the sternum is depressed inward, giving the chest a sunken appearance. However, pectus excavatum itself does not directly cause retractions but can be associated with increased respiratory effort.
D.   Atelectasis refers to the collapse of part or all of a lung, leading to decreased lung volume. This condition often results in increased respiratory effort and can be associated with intercostal retractions as the body struggles to expand the collapsed lung areas and improve ventilation.
E.   Obstruction of the airways, such as from a foreign body, mucus plug, or severe bronchoconstriction, can lead to increased respiratory effort as the client tries to overcome the obstruction. This increased effort often results in visible signs of respiratory distress, including intercostal retraction.

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Correct Answer is C

Explanation

A. This position is often seen in clients with chronic respiratory conditions like emphysema. It is called the tripod position and can help the client breathe more easily by expanding the chest and reducing the work of breathing. While this position indicates the client is experiencing difficulty breathing, it is not an immediate emergency but rather a sign of their chronic respiratory condition.

B. Fine crackles (or rales) are abnormal lung sounds that can indicate fluid in the alveoli. In emphysema, crackles are not typical and may suggest a complication such as pulmonary edema or infection.
However, if these crackles are not severe and the client’s overall condition is stable, it may not be the
most urgent issue compared to other findings.
C. A respiratory rate of 9 breaths per minute is considered bradypnea, which is significantly lower than the normal range (12-20 breaths/min). For a client with chronic emphysema on oxygen therapy, bradypnea is a concerning finding because it indicates inadequate respiratory drive and potential respiratory depression.
D. A barrel chest is a common physical finding in clients with chronic emphysema due to chronic air trapping and lung overexpansion. It reflects long-standing changes in the chest structure due to the disease. While it is a notable finding, it is a chronic manifestation of emphysema and not an immediate concern in the context of acute clinical status.

A. Wheezes B. Low pitched, grating rubbing sound C. Crackles D. Gurgling

Correct Answer is B

Explanation

A. Wheezes are high-pitched, continuous sounds that occur during expiration (and sometimes inspiration) due to narrowed airways, commonly seen in conditions like asthma or chronic bronchitis. They are not typically associated with pleural inflammation.
B. This description matches a pleural friction rub. A pleural friction rub is a low-pitched, grating or rubbing sound that occurs when inflamed pleural surfaces rub against each other. It is characteristic of pleural inflammation and is best heard during both inspiration and expiration. This sound results from the roughened pleural surfaces due to inflammation and is the expected finding in a patient with pleuritis.
C. Crackles (or rales) are discontinuous, high-pitched sounds heard typically during inspiration, caused by the opening of collapsed or fluid-filled alveoli. They are commonly associated with conditions like pneumonia, congestive heart failure, or pulmonary fibrosis, rather than pleural inflammation.
D. Gurgling is not a standard term for describing lung sounds. It may refer to rhonchi, which are low- pitched, continuous sounds heard due to mucus or fluid in the larger airways. Rhonchi can be heard in conditions like bronchitis or pneumonia but are not specifically associated with pleural inflammation.

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The nurse is observing the respiratory effort of a client, and notes that the client's intercostal spaces are retracting on inspiration. The nurse will assess the client for the presence of which condition(s)? Select All That Apply

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is evaluating and assessing a client with a diagnosis of chronic emphysema. The client is receiving oxygen therapy at a flow rate of 5 L/min via nasal cannula. Which findings concern the nurse immediately?

Correct Answer is C

Explanation

A client with a diagnosis of pleural inflammation is admitted to the hospital with respiratory distress. Which type of adventitious lung sounds should the nurse expect to hear upon auscultation?

Correct Answer is B

Explanation

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