A male client arrives at the clinic for follow-up health assessment after recent antibiotic treatment for pneumonia without hospitalization. Which technique should the nurse implement to assess for adventitious lung sounds?

Have the client lay flat while listening to the anterior surface of the chest.

Use the bell of the stethoscope to listen to the lung fields over lower lobes.

Shave all chest hair that may distort sounds heard through the diaphragm.

Press the stethoscope's diaphragm firmly on the skin over each lung field.

Answer and Explanation

The Correct Answer is D

Choice A Reason:
Having the client lay flat while listening to the anterior surface of the chest is incorrect because having the client lay flat may not be the most optimal position for auscultating lung sounds. While auscultation of the anterior surface of the chest is important, particularly for assessing the upper lobes of the lungs, having the client lay flat may not provide the best positioning for detecting all lung sounds, especially those located in the posterior lung fields.
Choice B Reason:
Using the bell of the stethoscope to listen to the lung fields over lower lobes is incorrect because using the bell of the stethoscope is more suitable for detecting low-frequency sounds such as heart murmurs or bruits. Adventitious lung sounds, such as crackles (rales) or wheezes, are typically high-pitched sounds that are best heard using the diaphragm of the stethoscope. Therefore, using the bell may not be the most effective technique for assessing adventitious lung sounds.
Choice C Reason:
Shaving all chest hair that may distort sounds heard through the diaphragm is incorrect because while removing chest hair may improve sound transmission for certain auscultatory findings, such as heart sounds, it is not specifically indicated for assessing adventitious lung sounds. Chest hair removal is not necessary for auscultation of lung sounds with the diaphragm of the stethoscope, as the sound transmission through chest hair is minimal and unlikely to significantly distort lung sounds.
Choice D Reason:
Pressing the stethoscope's diaphragm firmly on the skin over each lung field is correct because using the diaphragm of the stethoscope and pressing it firmly on the skin over each lung field ensures good contact with the chest wall, allowing for optimal transmission of lung sounds. Adventitious lung sounds, such as crackles or wheezes, are best heard using the diaphragm, particularly when it is applied firmly to the chest wall to minimize external noise and enhance sound transmission. Therefore, this technique is the most appropriate for assessing adventitious lung sounds during auscultation.

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Free Nursing Study Resources

Correct Answer is ["C","D","E"]

Explanation

C. Chronic obstructive pulmonary disease (COPD): COPD is a chronic respiratory condition characterized by airflow limitation, typically caused by chronic bronchitis and/or emphysema. In COPD, the airways become narrowed and inflamed, leading to difficulty breathing. Over time, chronic hypoxia (low oxygen levels in the blood) can develop due to impaired gas exchange in the lungs. Chronic hypoxia can trigger compensatory mechanisms in the body, including vascular changes that result in clubbing of the nails. Therefore, clubbed nails can often be seen in individuals with COPD as a consequence of chronic tissue hypoxia.

D. Lung cancer: Lung cancer is a malignant tumor that arises from the cells of the lungs. It is often associated with long-term smoking, as in the case of this client. Lung cancer can impair lung function and compromise gas exchange, leading to chronic hypoxia. As with COPD, chronic hypoxia can induce vascular changes that result in clubbing of the nails. Therefore, clubbed nails can be a manifestation of advanced lung cancer, particularly in cases where chronic hypoxia is present due to impaired lung function.

E. Chronic bronchitis: Chronic bronchitis is a type of chronic obstructive pulmonary disease (COPD) characterized by inflammation and narrowing of the airways, leading to excessive mucus production and persistent cough. Similar to other forms of COPD, chronic bronchitis can result in chronic hypoxia due to impaired gas exchange in the lungs. The chronic hypoxia associated with chronic bronchitis can lead to vascular changes that cause clubbing of the nails over time. Therefore, individuals with chronic bronchitis may also exhibit clubbed nails as a consequence of chronic tissue hypoxia.

A. Report the client's abnormal lung sounds to the healthcare provider. B. Continue with the remainder of the client's physical assessment. C. Ask the client to cough and then auscultate at the site again. D. Measure the client's oxygen saturation with a pulse oximeter.

Correct Answer is B

Explanation

Choice A Reason:
Reporting the client's abnormal lung sounds to the healthcare provider is inappropriate. This option is not appropriate because vesicular breath sounds are actually normal lung sounds. They are soft, low-pitched sounds heard predominantly during inspiration in the peripheral lung fields. Reporting them as abnormal would be incorrect and could potentially lead to unnecessary concern or intervention.
Choice B Reason:
Continuing with the remainder of the client's physical assessment is appropriate. Vesicular breath sounds in the bases of both lungs posteriorly are normal findings. They indicate adequate ventilation and airflow in the lower lung fields. Therefore, there is no need for immediate intervention or further assessment specific to this finding. Continuing with the remainder of the physical assessment is appropriate to assess other aspects of the client's health.
Choice C Reason:
Asking the client to cough and then auscultate at the site again is inappropriate. Asking the client to cough and then auscultate again is not necessary in response to hearing vesicular breath sounds. Vesicular breath sounds are normal lung sounds and do not require further assessment or intervention. Coughing would not change the character of vesicular breath sounds.
Choice D Reason:
Measuring the client's oxygen saturation with a pulse oximeter is inappropriate. While measuring oxygen saturation with a pulse oximeter is an important assessment, it is not specifically indicated in response to hearing vesicular breath sounds. Vesicular breath sounds indicate normal ventilation and airflow in the lower lung fields, but they do not provide direct information about oxygenation status. Oxygen saturation should be assessed as part of a comprehensive respiratory assessment, but it does not need to be prioritized solely based on the finding of vesicular breath sounds.
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A male client arrives at the clinic for follow-up health assessment after recent antibiotic treatment for pneumonia without hospitalization. Which technique should the nurse implement to assess for adventitious lung sounds?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Patient Data Exhibits The nurse reviews client data. Select the 3 possible conditions that could have the symptom of clubbed nails for this client.

Correct Answer is ["C","D","E"]

Explanation

While auscultating a client's breath sounds, the nurse hears vesicular sounds in the bases of both lungs posteriorly. Which action should the nurse take in response to this finding?

Correct Answer is B

Explanation

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