A nurse is assessing the breath sounds of an adult client who has pneumonia. Which of the following actions should the nurse take?
Place the bell of the stethoscope on the client's chest.
Follow a systematic pattern from side-to-side moving down the client's chest.
Ask the client to breathe in deeply through his nose.
Instruct the client to sit erect with their head tilted slightly backward.
The Correct Answer is B
A. "Place the bell of the stethoscope on the client's chest." The diaphragm of the stethoscope, not the bell, should be used to auscultate breath sounds because it is designed for high-pitched sounds like lung sounds.
B. "Follow a systematic pattern from side-to-side moving down the client's chest." To accurately compare breath sounds bilaterally, the nurse should use a side-to-side pattern, moving down the chest and back. This ensures a proper assessment of any asymmetry or abnormal sounds.
C. "Ask the client to breathe in deeply through his nose." The client should be instructed to breathe deeply through their mouth, not their nose, to enhance the clarity of breath sounds.
D. "Instruct the client to sit erect with their head tilted slightly backward." The ideal position for auscultating lung sounds is sitting upright with shoulders relaxed and slightly forward, allowing full lung expansion. Tilting the head backward is unnecessary.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Translucent, red tissue Granulation tissue is red or pink due to increased blood supply and is a sign of healing.
B. Soft, yellow tissue This describes slough, which consists of dead tissue and debris that may delay wound healing.
C. Stringy, white tissue This could indicate fibrin or slough, which may require debridement.
D. Thick, black tissue This describes eschar, which is necrotic (dead) tissue and needs removal for proper wound healing.
Correct Answer is ["A","B","C","D"]
Explanation
Cardiopulmonary:
Encourage deep-breathing exercises.
Check for pain.
Rationale:
Encouraging deep-breathing exercises helps improve oxygenation and prevent complications such as atelectasis, especially since the client's oxygen saturation initially dropped but improved with deep breathing.
Checking for pain is essential as the client has been prescribed PRN morphine for pain management.
"Inform client to achieve two to four breaths per session when using an incentive spirometer" is not selected because while incentive spirometer use is encouraged, the prescribed plan instructs use every hour while awake rather than focusing on a specific number of breaths per session.
Gastrointestinal:
Promote intake of oral fluids.
Apply barrier ointment after bowel movements.
Rationale:
Promoting oral fluid intake helps prevent dehydration and supports bowel function, especially since the client reports multiple loose stools and nausea/vomiting.
Applying barrier ointment after bowel movements helps protect the skin from irritation and breakdown due to frequent loose stools.
"Encourage the client to increase fiber in their diet" is not selected because fiber intake is usually increased for constipation, whereas in this case, the client has diarrhea, and fiber could worsen symptoms.
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