A nurse is caring for a 46-year-old male client in the emergency department who is experiencing difficulty breathing that has worsened over the last 24 hours.

Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client’s progress.

Answer and Explanation

The Correct Answer is []

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Correct Answer is B

Explanation

Choice A rationale
Placing the stethoscope over the clavicle is not the correct starting point for systematically auscultating anterior breath sounds.
Choice B rationale
The nurse should begin by placing the stethoscope over the lung apex, which is located just above the clavicle. This ensures a systematic approach to auscultation.
Choice C rationale
The aortic site is not relevant for auscultating breath sounds; it is used for cardiac auscultation.
Choice D rationale
Placing the stethoscope over the sternum is not the correct starting point for auscultating breath sounds.

A. Document the presence of borborygmi. B. Auscultate the remaining quadrants. C. Elevate the head of the client’s bed immediately. D. Use the bell of the stethoscope to auscultate again.

Correct Answer is B

Explanation

A. Document the presence of borborygmi.Loud, high-pitched, and almost continuous gurgling sounds can indicate borborygmi.However, the nurse should not immediately document without fully assessing all four quadrants to ensure a comprehensive evaluation of bowel sounds.

B. Auscultate the remaining quadrants.A complete assessment of bowel sounds involves auscultating all four quadrants to determine if the sounds are generalized, localized, or absent in other areas. This provides a more accurate assessment of the client’s gastrointestinal function.

C. Elevate the head of the client’s bed immediately.The client’s position does not typically affect bowel sounds, and elevating the head of the bed is unnecessary unless the client has difficulty breathing or other non-gastrointestinal concerns.

D. Use the bell of the stethoscope to auscultate again.Using the bell, which is intended for low-pitched sounds like bruits or heart murmurs, would not provide any additional relevant information.

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Naxlex Comprehensive Predictor Exams

When systematically auscultating a client’s anterior breath sounds, the nurse should begin by placing the stethoscope over which location?

Correct Answer is B

Explanation

After placing a client in a supine position, the nurse uses the diaphragm of the stethoscope to auscultate bowel sounds and hears a loud, high-pitched almost continuous gurgling in two quadrants. Which action should the nurse implement first?

Correct Answer is B

Explanation

An older male client reports to the nurse that his feet are cold. Before covering the client’s feet, which assessment(s) should the nurse complete? Select all that apply.

When family members express their concern about their father’s recent memory loss, which assessment should the nurse suggest?

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