d) Deviation from the midline
Explanation:
During the physical examination, the nurse must inspect and gently palpate the trachea to assess for placement and deviation from the midline. The trachea is normally in the midline as it enters the thoracic inlet behind the sternum, but it may be deviated by masses in the neck or mediastinum. Pulmonary disorders, such as a pneumothorax or pleural effusion, may also displace the trachea. The
nurse examines the posterior pharynx and tonsils with a tongue blade and light, and notes any evidence of swelling, inflammation, or exudate, as well as changes in color of the mucous membranes. The nurse also examines the anterior, posterior, and lateral chest walls for any evidence of muscle weakness.
a) Asking the patient to repeat "ninety-nine" as the nurse's hands move down the patient's thorax
Explanation:
While the nurse is assessing for
tactile fremitus, the patient is asked to repeat "ninety-nine" or "one, two, three," or "eee, eee, eee" as the nurse's hands move down the patient's thorax. The vibrations are detected with the palmar surfaces of the fingers and hands, or the ulnar aspect of the extended hands, on the thorax. The hand or hands are moved in sequence down the thorax. Corresponding areas of the thorax are compared. Asking the patient to say "one, two, three" while auscultating the lungs is not the proper technique
for assessing for tactile fremitus. The nurse assesses for anterior respiratory excursion by placing the thumbs along the costal margin of the chest wall and instructing the patient to inhale deeply. The nurse assesses for diaphragmatic excursion by instructing the patient to take a deep breath and hold it while the diaphragm is percussed.