Transcript Review chest X-ray - Kingwood Application Server

Review chest X-ray
By Elizabeth Kelley Buzbee AAS,
RRT-NPS, RCP
Lone Star College: Kingwood
Respiratory Care Program
1. In the chest x-ray of a person with
pneumocystis carinii pneumonia
(PCP) one would most likely
see______ because this diseases
progresses rapidly to ARDS.
a. lobar consolidation
b. pneumomatoceles
c. Kerley B lines in the bases
d. left-sided effusions
e. diffuse tiny opacities & air
bronchograms
answer
e. diffuse tiny opacities & air
bronchograms
because this is what we see in an alveolar
problem. We would see this in any diffuse
pneumonia or in ARDS or IRDS.
2.
In the chest X-ray of a person
with staphylococcal pneumonia one
would most likely see :
a. lobar consolidation
b. pneumomatoceles
c. Kerley B lines in the bases
d. left-sided effusions
e. diffuse tiny opacities and air
bronchograms
answer
b. Pneumomatoceles
a pneumomatocele is a air-filled cavity that
shows up in 24 hours or less. They will be
seen in staph pneumonia and in aspiration
of hydrocarbons.
3. In the chest X-ray of the patient with left
sided pleuritic pain and diminished LLL
breath sounds, one might expect to see:
a. LUL consolidation
b. pneumomatoceles
c. Kerley B lines
d. left-sided effusions
e. diffuse tiny opacities and air bronchograms
answer
d. left-sided effusions
Effusions will be seen as homogenous
opacities that collect in the plural space in
the dependent part of the thorax. One
would have dullness to palpation and
chest pain from the pluresy that would
accompany the effusion
4. Kerley B lines are seen:
I.
ii.
iii.
iv.
when alveoli are full of fluid
when interstitial spaces are edematous
in tuberculosis
in pulmonary edema
a. i and iv
b. ii and iv
c. iii only
d. iii and iv
answer
b. ii and iv
Kerley B line are short, horizontal lines seen
on the bases of the lung. The lines reflex
thickened alveolar septal walls.
They are seen in diffuse interstitial disorders
such as interstitial pneumonia, pulmonary
edema [interstitial and alveolar filling
patterns]
5. One would see an air bronchogram
at the level of the RML in an area of:
a. consolidation
b. air trapping
c. atelectasis
d. abscess
answer
Consolidation
Consolidation is an alveolar filling pattern
where the air is replaced by fluid. Fluid is
white [opaque] on the X-ray
Because the airway is black, we now see the
airway against the white opacities
a.
6.
Persons with emphysema
would most likely have the following
on chest film:
a. right-sided pleural effusion
b. bullea/ bleb
c. Kerley B lines
d. abscess
answer
b. bullea/ bleb
 Is an air pocket, seen in serious
airtrapping. These will be seen in
empysema and COPD.

7. Within a few hours of the incident,
a baby who has aspirated a toy
would most likely have distal to
the obstruction:
a. consolidation
b. a cavitation
c. atelectasis
d. abscess
e. a or c are both possible
answer
e. a or c are both possible
If the baby inhales a foreign object that
completely cuts off gas flow to the lower
airways, then there will be atelectasis
If the object only causes a ball-valve
obstruction, the there can be localized
airtrapping below the object
8. If one sees homogenous opacities
in the RML & narrowed intercostal
spaces overlying this area, one is
seeing:
a. RML consolidation
b. localized RML airtrapping
c. RML atelectasis
d. a RML mass
answer
c. RML atelectasis
One of the signs of atelectasis is a movement of
adjacent objects into the place where the lung
has collapsed. Ribs will be closer together and
fissures may move toward the atelectasis
While atelectasis is opaque like consolidation,
there will be no air-bronchograms in atelectasis
It is possible to have both atelectasis and
consolidation in the same patient with many
alveolar disorders
9. A thick walled opacity with an
air/fluid interface is most likely:
a. consolidation
b. a mass
c. atelectasis
d. abscess
e. b or c are possible
answer
d. abscess
An abscess is a thick-walled opacity that is
filled with pus. It is caused by a
necrotizing bacterial pneumonia.
If the abscess ruptures into an airway, we
might see the air/fluid interface inside the
abcess
10. A tumor compressing the RUL
bronchus could result in:
a. RUL abscess
b. RUL consolidation
c. RUL atelectasis
d. both a and b
e. both b and c
answer
e. both b and c
Just like the F.O. a tumor compressing the
airway can cause atelectasis &
consolidation downstream
If the tumor is smaller, it might cause a ball
valve obstruction and result in a localized
airtrapping and you might hear a wheeze
over one spot—that will not respond to
bronchodialators
11. When compared to viral pneumonia,
bacterial pneumonias are more associated
with:
i. diffuse alveolar opacities with air bronchograms
ii. localized alveolar opacities with air bronchogram
iii. abscesses
iv. cavitations
a. i, iii
b. ii, iii
c. ii, iii and iv
d. i only
answer
c. ii, iii and iv
Viral pneumonias tend to be diffuse, while
bacterial pneumonias will be characterized
by local problems such as abscesses,
effusions or cavitations
12. Immediately after drainage of a small right-sided
empyema by needle aspiration, a AP chest film is ordered.
You see an area of hyperlucency without lung markings in
the RUL. The heart shadow is almost completely to the left
of the sternum. What has happened?
a. the needle has successfully aspirated the fluid from the
empyema
b. the needle was too small, the fluid is too thick and the
aspiration attempt was not successful. A chest tube must be
inserted.
c. the needle has punctured the lung and a tension
pneumothorax has resulted
answer
c. the needle has punctured the lung and a
tension pneumothorax has resulted
The heart has shifted, and the
hyperlucency is air in the chest. This is a
common hazard of thoracentesis.
All procedures involving a needle and the
chest must be followed by a chest x-ray to
rule out pneumothorax
13. Immediately after the insertion of a flow
directed pulmonary artery catheter, a
chest film is ordered. You see a radiopaque
line enter the right subclavian vein and
you see that the tip of the catheter is in
the right atrium.
a. the catheter has migrated into the wedged position
b. the catheter is not inserted far enough
c. the catheter is in the proper position
d. the catheter has transected the right subclavian
vein
answer
c b. the catheter is not inserted far
enough
The RA is an excellent position for a central
line but the pulmonary artery catheter
should sit in the pulmonary artery

14. Immediately after a right-sided chest
tube has been removed from the 3rd
intercostal space in the anterior, a chest
film is ordered. You see that there are lung
markings from the hilar down to the
pleura in the right apical area. This
probably means that:
a. the effusion has returned, the chest tube may need
to be reinserted.
b. the pneumothorax has returned, the chest tube
may need to be reinserted.
c. there in now a pulmonary infarction in this are
d. the pneumothorax has resolved
answer
d. the pneumothorax has resolved
You want to see lung markings all the way to
the plural. We know that the most common
site for a chest tube to drain a pneumothorax
is in the anterior upper chest
15. Signs of cardiogenic pulmonary edema
include the following:
i. Kerley B lines
ii. cardiomegaly
iii. increased opacities in the hilar area, in a butterfly
pattern
iv. segmental airtrapping
a. i, ii, iii and iv
b. ii, iii only
c. i, ii only
d. i, ii, iii
Answer
d. i, ii, iii
In all pulmonary edema we will see alveolar
filling patterns and thickened alveolar
septal walls, but if the heart is enlarged, it
is cardiogenic pulmonary edema
Another sign it is cardiogenic is the butterfly
pattern [or bat wing] created by engorged
pulmonary arteries
16. Air bronchograms are seen in cases
of alveolar consolidation, because
the opacity of the consolidation
creates a contrast to the
radiolucency of the airway as it lies
over the area of consolidation.
a. true
b. false
Answer
a. true
Just like a black cat disappears in a dark
room, we don’t normally see the black
airways against black [air filled] alveoli
if the alveoli are filled with fluid we now see
the black airways against the opaque
17.Diffuse
lesions of tiny opacities of
less than 4 mm in diameter are seen
in varicella pneumonia. This is also
seen in:
a. diffuse pulmonary tuberculosis
b. multiple fat emboli
c. ARDS
d. no other lung disorder
Answer
diffuse pulmonary tuberculosis
When one has dissiminated TB, there are
tiny opacities that look like millet seeds.
This is seen in chicken pox pneumonia
also…very bad sign
a.
18. It is not possible for one to have a
combination of diffuse interstitial and
alveolar filling patterns in the same
patient who is diagnosed with noncardiogenic pulmonary edema.
a. true
b. false
Answer
False
 Because both interstitial and alveolar
filling patterns are seen in problems with
the alveoli, you can have both show up in
the X-ray. These persons will have low
compliant lungs and refractory hypoxemia

19. A person who has flattened
diaphragms with wide intercostal
spaces and bronchial thickening
would most likely have:
a. emphysema
b. bilateral pneumothorax
c. bilateral effusions
d. a lobectomy
e. pulmonary infarction
Answer
a. emphysema
the intercostal spaces are widened by
airtrapping, the bronchial walls are
thickened by secretions and the
diaphragm has been pushed down by the
airtrapping
20. The mediastinal structures tend to
shift towards a
:
a. pneumothorax
b. an area of airtrapping
c. an area of atelectasis
d. an area of consolidation
e. c and d
Answer

c. an area of atelectasis
Structures move away from pneumothorax
or from airtrapping
 Nothing moves in consolidation

21. Mr. Reese had a LLL lobectomy. Several
months after this surgery, one would not
be surprised to find what abnormal
findings on a PA chest film ?
a. the LUL seems smaller or seems pulled to the right
b. the LUL seems to be larger and it's inferior borders
seem to bulge into the space where the LLL used to
be. The heart seems to be more on the left than
normal
c. there is a hyper-lucency in the LLL and the left
hemi-diaphragm is depressed
d. there will be no changes
Answer
b. the LUL seems to be larger and it's inferior
borders seem to bulge into the space where
the LLL used to be. The heart seems to be
more on the left than normal
Remember: objects move into a vacuum
when the lung is removed, the other lobes
move into the area—the fissures will be
altered
22. When looking at a RUL pneumothorax,
one would expect to see:
i. hyperlucency without lung markings in the RUL
ii. hyperlucency without lung marking in a column
on the right side of the heart.
iii. the superior aspect of the RML may be opaque
iv. the 3rd-5th right intercostal spaces will be closer
together than the same intercostal spaces on the left
a. i, iii only
b. ii, iii only
c. i, iv only
d. i, iii and iv
Answer

a. i, iii only
Pneumthorax always show up as
hyperlucency
 The air would push on the superior aspect
of the RML so that it starts to collapse. It
will become opaque

23. When the right hemi-diaphragm is
paralyzed, one would see what
derangement on the PA chest film during
the inspiratory phase?
a. the right hemi-diaphragm is 2 cm higher than the
left
b. the right hemi-diaphragm is 2 cm lower than the
left
c. the right hemi-diaphragm is 4 cm higher than the
left
d. the right hemi-diaphragm is 4 cm lower than the
left
Answer
c. the right hemi-diaphragm is 4 cm higher than
the left
– This is tricky. Remember: the normal position
for the right hemi-diaphragm is to be 2 cm
higher than the left. When the diaphragm is
paralyzed, it sits in the resting position which
is up so the right is higher than it should be.
24. A homogenous opacity located in
the basal aspect of the LLL which
causes the costophrenic angle to be
blunted would most likely be a (an):
a. LLL consolidation
b. LLL atelectasis
c. left sided effusion
d. none of these
Answer

c. left-sided effusion

Blunting of the costophrenic angle is
caused by fluid in the plural cavity. Fluid is
opaque.
25. If you were to see an area in the LUL,
which you would describe as a sharp and
distinct round opacity you might be
describing a/an:
a. cavitation
b. pneumatocele
c. bullae or bleb
d. abscess without an air/fluid interface
e. an abscess with an air/fluid interface
Answer
d. abscess without an air/fluid interface
Cavitations, bullae or blebs & pneumatoceles
are all black because they are filled with air
26. A mass is:
i.
ii.
iii.
iv.
a sharply demarcated homogenous opacity
a sharply demarcated hyperlucency
less than 4 cm in diameter
more than 4 cm in diameter
a. i, iv
b. ii, iv
c. i, iii
d. ii, iii
Answer

b. ii, iv

The only difference between a nodule and
a mass is the size. Both are opacities that
replace normal tissue
27. Wide-spread multiple nodules of
less than 4 mm in diameter are called
a milliary pattern.
a. true
b. false
Answer
True
 Tiny opacities look like millet seeds

28. The presence of a single nodule in
the lung fields is:
a. never a sign of bronchogenic carcinoma
b. always seen in bronchogenic carcinoma
c. is most likely not lung cancer if it is calcified
Answer
c. is most likely not lung cancer if it is calcified
Single nodules may or may not be cancer,
but they are less likely to be if they are
calcified
29. You view a PA upright chest film.
The heart is 12 cm wide and the
internal diameter of the thorax is 20
cm wide.
a. there is cardiomegaly
b. there is hepatomegaly
c. the heart size is WNL
Answer

A. cardiomegally

The heart should be able to fit into the
internal chest at the level of the
diaphragms twice. If not, there is
cardiomegally. This is also called the CT
ratio [cardiothoracic ratio] 1:2 is normal
30. To find a mass that is pushing the
trachea toward the anterior you
would require a
type of x-ray.
a. apical lordotic
b. lateral chest
c. bronchogram
d. lateral decubitus
Answer
b. lateral chest

A side view would see the object that is
shifted forward or backwards from its
normal position
31. Normally the right hilum is at least:
a. 2 cm higher than the left
b. 2 cm lower than the left
c. 5 cm higher than the left
d. 5 cm lower than the left
answer
b. 2 cm lower than the left

The left hilum is pushed up to make room
for the heart
32. To visualize an apical mass better
one might want to see a x-ray.
a. apical lordotic
b. lateral chest
c. bronchogram
d. lateral decubitus
e. PA standard upright
answer
a. apical lordotic
 This view looks up at the apical area from
an angle that spreads out the structures
so that mass in the apical area could be
seen better if it was hidden behind
something

33. Of the following x-ray densities, which is
the MOST RADIO-LUCENT?
a. water
b. air
c. bone
d. fat
e. tissue
answer

b. air
Radiolucent is black, so air is the darkest
 Metal is most opaque, then heart, then
thicker fluid.

34. When viewing a PA standard, if the
sternal notch does NOT lie over the
vertebral column and the left clavicle
is 2 cm higher than the left, the Xray
is:
a. an example of good technique
b. not well centered
c. over penetrated
d. under-penetrated
e. done on exhalation, not end inspiration
answer

b. not well centered

Like any photograph if the picture is lined
up right, the sternum should be right over
the vertebral column
35. When viewing a PA standard, if the
diaphragms extend only to the level
of the 4th anterior intercostal space,
this chest film is:
a. an example of good technique
b. not well centered
c. over penetrated
d. under-penetrated
e. done on exhalation, not end inspiration
answer
e. done on exhalation, not end inspiration
On a deep inspiration the diaphragm should
be down to the level of the 6th – 6th
intercostal spaces
36. If you are unable to tell if the
patient has suffered a pneumothorax
or has airtrapping because of the
general darkness of the film, your xray is :
a. an example of good technique
b. not well centered
c. poorly penetrated
d. a bronchogram
e. done on exhalation, not end inspiration
answer
c.
poorly penetrated
Like any other photograph, an X-ray can be
over-exposed or under-exposed. Both
are problems. You want to be able to see
the vertebra through the heart
37. The patient faces the film. The rays enter
from his back and the tube is placed at a
45 degree angle below the patient and the
film. This describe the following
technique:
a. oblique
b. lateral chest
c. apical lordotic
d. apical decubitus
e. lateral neck
answer

c. apical lordotic. This view is used to
separate close structures to see objects in
the apical lobes better
patient
answer
38. To find retro-sternal air one would
want to do a
film.
a. oblique
b. lateral chest
c. apical lordotic
d. apical decubitus
answer
b. lateral chest
When the picture is taken from the side, the air
behind the sternum that collects in
airtrapping, will be seen as a blackness just
behind the breast bone.
This is responsible for creating the barrel chest
39. To find a lung lesion hidden behind
a structure one could do the
following:
a. oblique
b. lateral chest
c. apical lordotic
d. apical decubitus
e. all but d could be used to find hidden lesions
answer
e. all but d could be used to find hidden
lesions
The lateral is from the side, the oblique view
is when the x-ray tube is moved to the
right or the left to see objects better & the
apical lordotic spreads out the objects in
the picture
There is no such animal as the apical
decubitus
40. This view is used to find free fluid
in the pleural cavity.
a. lordotic
b. oblique
c. lateral decubitus
d. bronchogram
e. c and d
answer
c. lateral decubitus
In a lateral decubitus, the patient lies on his
side and any free fluid in his chest will
layer out along the mattress. This layering
of fluid is call the ‘gutter’
The picture is taken from the front.
41. When looking at the chest film of a
newborn infant, one must remember that
one would normally see the following:
a. there are only 10 ribs
b. the thymus gland is huge
c. the ribs are mostly cartilage and seem thin
d. a and c
e. b and c
answer
e. b and c
the babies bones are mostly cartilage so
they seem thin
 The thymus gland is so huge in an infant
that it looks like there are bilateral apical
opacities near the midline—or that there is
something wrong with the cardiac shadow

42. One would want to see an endexpiratory film to look for the
following:
a. small pneumothorax
b. localized airtrapping
c. small effusion
d. a and b
e. a, b and c
answer
d. a and b
if the picture is taken on exhalation, small
areas of black will show up better against
the general whiteness of the exhalation
shot
43. The injection of a contrast media
into the pulmonary vasculature to
observe the blood flow is done to
diagnosis the following:
a. pulmonary embolism
b. pulmonary artery stenosis
c. pleural effusion
d. a and b
e. a and c
answer
d. a and b

An angiogram used contrast media to see
arteries better, a venogram is used to see
viens.
45. Injection of tagged albumin into the
pulmonary vasculature which is followed
by an inhalation of a couple of breaths of a
xenon gas to create a "dot matrix" type of
a picture is a description of what type of
radiographic technique:
a. bronchogram
b. angiogram
c. CAT scan
d. ventilation/ perfusion scan
answer
d. ventilation/ perfusion scan
A V/Q scan is used to screen for
pulmonary emboli because the ventilation
and the perfusion should match. If there is
ventilation without perfusion, then there is
an obstruction to blood flow
 Ventilation and perfusion both down may
only reflect the pulmonary
vasoconstriction seen in alveolar hypoxia

46. The quickest, least invasive way to
diagnosis pulmonary emboli is to perform
the following:
a. bronchogram
b. angiogram
c. CAT Scan
d. ventilation/ perfusion scan
answer
d. ventilation/ perfusion scan
The V/Q scan is quick and can be done at
the bedside
answer
47. The procedure,most likely to be the
most accurate method to diagnosis
pulmonary embolism is to perform the
following:
a. bronchogram
b. angiogram
c. CAT Scan
d. ventilation/ perfusion scan
answer
b. Angiogram
The V/Q scan will miss about half of the
pulmonary emboli, while the angiogram will
catch most of them.
The angiogram involves insertion of a flow
directed pulmonary artery catheter, so it is
dangerous and invasive—and expensive
Reference page
Pathological films & techniques:
 George Burton’s Respiratory Care 4th ed.
Techniques:
 Wilkin’s Respiratory Assessment