A nurse is examining a client for tactile fremitus. The nurse should understand that what action is of primary importance when examining for tactile fremitus?

Palpate the chest symmetrically

Ask the client to cough

Use the bell of the stethoscope

instruct the client to breathe deeply

Answer and Explanation

The Correct Answer is A

A) Palpate the chest symmetrically:
Palpating the chest symmetrically is crucial when assessing tactile fremitus, as it allows the nurse to compare the intensity of vibrations felt on both sides of the chest. Tactile fremitus refers to the palpable vibrations transmitted through the bronchopulmonary system when a person speaks or breathes. Symmetrical palpation ensures that the nurse can detect any differences in fremitus, which may indicate abnormalities such as lung consolidation (e.g., pneumonia), pleural effusion, or pneumothorax. Uneven fremitus can suggest a pathological condition, and symmetrical palpation helps identify these variations.

B) Ask the client to cough:
Asking the client to cough is not directly related to the assessment of tactile fremitus. Coughing may be used in other aspects of the respiratory assessment (e.g., to clear secretions or to assess for a productive cough), but it is not necessary for palpating fremitus. Tactile fremitus is assessed while the client is speaking (e.g., repeating the phrase "ninety-nine") or breathing, not coughing.

C) Use the bell of the stethoscope:
The bell of the stethoscope is used for auscultating low-pitched sounds, such as heart murmurs or some lung sounds (e.g., certain adventitious sounds like crackles or wheezes). However, it is not used for palpating tactile fremitus, which is a physical exam technique that involves using the hands to feel for vibrations. Fremitus is a tactile (not auscultatory) finding, so the stethoscope, whether bell or diaphragm, is not relevant in this assessment.

D) Instruct the client to breathe deeply:
While it is important for the client to breathe deeply during a lung exam, deep breathing is not directly required for assessing tactile fremitus. Tactile fremitus is typically assessed while the client is speaking. When the client repeats a phrase like "ninety-nine," vibrations are transmitted through the chest wall, and the nurse can assess the intensity of the vibrations. Deep breathing would be more relevant for assessing breath sounds or the general respiratory effort.

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Correct Answer is B

Explanation

A) Demonstrate that both arteries will be palpated simultaneously to compare amplitude: This is not recommended. Palpating both carotid arteries simultaneously can cause a decrease in blood flow to the brain, potentially leading to dizziness or syncope. It is important to palpate one carotid artery at a time to avoid reducing blood flow to the brain, especially in clients with cardiovascular disease or those at risk of stroke.

B) Instruct the client to take a deep breath and "hold" while the nurse briefly auscultates: This is the correct approach. Instructing the client to hold their breath helps minimize any interference from respiratory sounds while auscultating the carotid arteries for bruits. This technique ensures that breath sounds do not mask any abnormal vascular sounds, such as bruits, which could indicate a blockage or narrowing of the carotid arteries.

C) Discuss that a light will be directed at the neck to observe for pulsations of the artery: Observing pulsations with light is not an appropriate technique for assessing the carotid arteries. Pulsations may be visible in some cases, but palpation and auscultation are the more reliable methods for evaluating the carotid arteries for abnormalities such as bruits or reduced pulse amplitude.

D) Show the client the diaphragm of the stethoscope that will be placed on the neck: While it is appropriate to explain the process to the client, the action of showing the stethoscope is unnecessary at this stage. The focus should be on instructing the client to hold their breath for proper auscultation to listen for any abnormal vascular sounds.

A. Both lungs are equal in size with varying numbers ‹ lobes B. The diaphragm rises in the chest during inspiration C. The left lung has two lobes to make room for the heart D. The right lung has two lobes to make room for the liver

Correct Answer is C

Explanation

A) Both lungs are equal in size with varying numbers of lobes:
This is incorrect. The right lung is slightly larger than the left lung, as the left lung is somewhat smaller to accommodate the heart. The right lung has three lobes, while the left lung has only two lobes.

B) The diaphragm rises in the chest during inspiration:
This is incorrect. During inspiration (inhalation), the diaphragm contracts and moves downward to allow the lungs to expand and fill with air. It rises during exhalation as it relaxes and pushes air out of the lungs.

C) The left lung has two lobes to make room for the heart:
This is correct. The left lung has two lobes (upper and lower) compared to the three lobes of the right lung. The left lung is slightly smaller due to the space the heart occupies on the left side of the chest, allowing for asymmetry between the two lungs.

D) The right lung has two lobes to make room for the liver:
This is incorrect. The right lung has three lobes, not two. The liver is located lower in the abdomen and does not influence the number of lobes in the right lung. The asymmetry of the lungs is due to the position of the heart on the left side of the chest.

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A nurse is examining a client for tactile fremitus. The nurse should understand that what action is of primary importance when examining for tactile fremitus?

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Naxlex Comprehensive Predictor Exams

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Explanation

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