A client has arrived at the clinic for a routine physical examination. Prior to assessing the client's blood pressure, what should the nurse do?

Position the arm so that it is below waist level.

Palpate the radial artery to confirm a pulse is present.

Ask the client to sit quietly in a chair for 5 minutes.

Make sure the arm selected is covered with clothing.

Answer and Explanation

The Correct Answer is C

Choice A Reason:
Positioning the arm below waist level is not recommended when measuring blood pressure. It can result in an inaccurate reading, typically showing a higher blood pressure due to the effects of gravity on the blood column. The arm should be positioned at heart level for an accurate measurement.

Choice B Reason:
While palpating the radial artery to confirm a pulse is present is part of the overall assessment of circulation, it is not a necessary step immediately before measuring blood pressure. The focus should be on ensuring the client is in the correct position and is relaxed to avoid any factors that might artificially alter the blood pressure reading.

Choice C Reason:
Asking the client to sit quietly in a chair for 5 minutes is the correct procedure before measuring blood pressure. This allows the client's heart rate and blood pressure to stabilize, providing a more accurate measurement. Any activity or stress can temporarily raise blood pressure, so this quiet time is crucial.

Choice D Reason:
The arm selected for blood pressure measurement should not be covered with clothing. Clothing can constrict the blood pressure cuff and interfere with the accuracy of the reading. The cuff should be placed on bare skin to ensure it inflates and deflates correctly and that the stethoscope can accurately detect the sounds of the blood flow.

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Correct Answer is D

Explanation

Choice a reason:
Bronchovesicular sounds are normal breath sounds heard over the main bronchus area and over the upper right posterior lung field. They have a medium pitch and intensity and are heard on both inspiration and expiration. Bronchovesicular sounds do not involve the change of vowel sounds during auscultation.

Choice b reason:
Bronchophony is the term used when the voice sounds are more clear and louder over the chest wall, usually indicating lung consolidation. However, it does not specifically refer to the change of vowel sounds from "ee" to "ay."

Choice c reason:
Normal voice resonance is when voice sounds heard through auscultation are muffled and indistinct. It does not involve a clear change in vowel sounds, which is what occurs with egophony.

Choice d reason:
Egophony is characterized by the change of the "ee" vowel sound to a nasal "ay" or "a" sound when auscultating the lungs. This phenomenon typically suggests lung consolidation, as might be seen with pneumonia.

A. Tracheal B. Vesicular C. Bronchovesicular D. Bronchial

Correct Answer is B

Explanation

Choice A Reason:
Tracheal sounds are harsh, high-pitched breath sounds typically heard over the trachea in the neck. They are not expected to be heard over the peripheral lung fields of a young adult during a routine lung auscultation.

Choice B Reason:
Vesicular breath sounds are the normal sounds heard over most of the lung fields. They are characterized by a soft, low-pitched, rustling sound during inhalation and are softer during exhalation. These sounds are created by air moving through the smaller airways such as the bronchioles and alveoli.

Choice C Reason:
Bronchovesicular sounds are heard over the major bronchi and are characterized by a moderate pitch and intensity. They are typically heard between the first and second intercostal spaces at the sternal border anteriorly and between the scapulae posteriorly, not over most of the lung fields.

Choice D Reason:
Bronchial breath sounds are high-pitched and louder than vesicular sounds, with a hollow quality, and are normally heard over the manubrium. If heard over the peripheral lung fields, they may indicate lung consolidation or other abnormalities.

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A client has arrived at the clinic for a routine physical examination. Prior to assessing the client's blood pressure, what should the nurse do?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is performing a respiratory system physical examination. To assess the resonance of voice sounds heard during auscultation of the lungs, the nurse instructs the patient to say "ee," and if the sound is heard as "ay," this is known as:

Correct Answer is D

Explanation

The nurse is preparing to auscultate the lung sounds of a young adult. Which sound will the nurse expect to hear over most of the client's lungs?

Correct Answer is B

Explanation

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