A nurse is auscultating for crackles on a client who has pneumonia. Which of the following anterior chest wall locations should the nurse auscultate? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)

Answer and Explanation

The Correct Answer is "{\"xRanges\":[132,167],\"yRanges\":[113.5,148.5]}"

A.   This area corresponds to the trachea which produces bronchial breath sounds which are inconsistent with lower airway disease as expected in pneumonia.
B.   This area corresponds to the right upper lung lobe which is accurate for auscultation for abnormal breath sounds such as crackles.
C.   This area corresponds to the right upper quadrant for auscultation for bowel sounds.
D.   This area corresponds to the cardiac region which is more accurate for auscultation of heart sounds.

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Correct Answer is A

Explanation

A. At 12 weeks of gestation, the fetal heart tones can typically be heard using a Doppler ultrasound device placed above the symphysis pubis.
B. A side-lying position is not required for assessing fetal heart tones at this gestational age.
C. Fundal height is more useful in later stages of pregnancy, and it is not necessary to measure it for assessing fetal heart tones at 12 weeks.
D. Leopold maneuvers are used to determine the position of the fetus, but they are not typically performed before assessing fetal heart tones.

A. Attach the restraint to the bed's side rails. B. Document the client's condition every 15 min. C. Request a PRN restraint prescription for clients who are aggressive. D. Remove the client's restraint every 4 hr.

Correct Answer is B

Explanation

A. Restraints should never be attached to the side rails, as this can increase the risk of injury.
B. The client's condition should be documented every 15 minutes to ensure their safety and comfort while in restraints.
C. A PRN prescription for restraints is not appropriate; restraints should be used only as a last resort and with a physician's order.
D. The restraint should be removed at least every 2 hours to assess for skin integrity and allow for range- of-motion exercises.

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System	Findings
General	Adult child accompanying parent reports decline in client, expressing concern over memory and thought process, appetite, and self-care. Adult child states, "My sibling and I hired help at home for my parent. We thought that would help but it has not. I found the title to the car today, signed over to me."
Physical	Client makes poor eye contact, speaks in a monotone voice, and has a lack of facial expression. Client reports sleeping 7 hr a night and getting up "once or twice per night to go to the bathroom." Client reports not wanting to eat anymore. Client's child reports their parent has lost about 8 lb in the past month. Heart rate 68/min
Affect	Client says, "Why don't you just leave me? I am of no use."

A nurse is auscultating for crackles on a client who has pneumonia. Which of the following anterior chest wall locations should the nurse auscultate? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to assess fetal heart tones for a client who is at 12 weeks of gestation. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse manager is updating protocols for the use of belt restraints. Which of the following guidelines should the nurse manager include?

Correct Answer is B

Explanation

A nurse is preparing to admit a 6-year-old with varicella to the pediatric unit. Which of the following actions should the nurse take?

A nurse is caring for a client who reports xerostomia following radiation therapy to the mandible. Which of the following is an appropriate action by the nurse?

A nurse is caring for a client who is at 33 weeks of gestation following an amniocentesis. The nurse should monitor the client for which of the following complications?

A nurse in an emergency department is reviewing the medical record of a client who is having an acute myocardial infarction. Which of the following findings places the client at risk if he receives alteplase?

The nurse continues to care for the client. Exhibits Which of the following actions should the nurse take? Select all that apply.