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 B,C,E,A,D
Explanation
- Assist the client into a sitting position in a chair. Ensures comfort and stability before starting foot care.
- Soak the client's feet in warm water. Softens the skin and makes cleaning easier.
- Rub callused areas of the client's feet using a washcloth. Helps remove dead skin and promotes circulation.
- Gently dry the client's feet and areas between the toes with a towel. Prevents moisture buildup, which can lead to fungal infections.
- Apply lotion to the client's feet. Moisturizes the skin but should not be applied between the toes to prevent excessive moisture retention and fungal growth.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"D"}
Explanation
- Oxygen Saturation (90%) – This is a drop from the initial 95% and indicates potential hypoxia. The increased respiratory rate and depth may be compensatory mechanisms.
- Behavioral Findings ("I feel like something is wrong.") – Clients experiencing early signs of deterioration often report a sense of unease. This, combined with agitation, could indicate worsening hypovolemia or hypoxia.
The client's low hemoglobin (8.3 g/dL) and hematocrit (32%) suggest significant blood loss during surgery, which could contribute to hypoxia and hemodynamic instability. Immediate follow-up is needed to assess for potential ongoing bleeding, oxygenation issues, or early signs of shock.
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