In assessing tactile fremitus in the client with suspected pneumonia, the nurse should perform which action?

Looking at the client from the side, observe the size and shape of the chest wall.

Use the fingertips to compress tissue over the lungs for evidence of a crackling sensation.

Place the palm of the hand on the chest wall to feel vibrations while the client speaks.

Use a stethoscope to listen to and compare breath sounds anteriorly and posteriorly.

Answer and Explanation

The Correct Answer is C

A) Looking at the client from the side, observe the size and shape of the chest wall:
This action is more related to inspecting the physical appearance and symmetry of the chest wall but does not assess tactile fremitus.

B) Use the fingertips to compress tissue over the lungs for evidence of a crackling sensation:
This action may be more relevant for assessing subcutaneous emphysema (crepitus) but is not the correct method for assessing tactile fremitus.

C) Place the palm of the hand on the chest wall to feel vibrations while the client speaks:
This is the correct action to assess tactile fremitus. By placing the palm of the hand on various areas of the chest wall while the client repeats a phrase such as "ninety-nine," the nurse can feel for vibrations. Increased tactile fremitus can indicate consolidation, as seen in pneumonia.

D) Use a stethoscope to listen to and compare breath sounds anteriorly and posteriorly:
This action involves auscultation, which is important for assessing breath sounds but does not assess tactile fremitus directly.

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Correct Answer is C

Explanation

A) Aortic site:
The aortic site is relevant for cardiac assessment but not for auscultating breath sounds.

B) Sternum:
The sternum is a bony structure and not an optimal location to start auscultating breath sounds as it can interfere with sound transmission.

C) Lung apex:
Auscultating at the lung apex, which is located just above the clavicle, is the appropriate starting point for assessing anterior breath sounds. This ensures that the upper parts of the lungs are examined first.

D) Clavicle:
While the area near the clavicle is relevant, it is more precise to refer to the lung apex, which includes the area just above the clavicle, for starting the auscultation of breath sounds.

A. Presents with a hacking nonproductive cough of 6 weeks duration. B. Expresses concern of "lung cancer" symptoms for last 6 weeks. C. An adult male presents with fears that he has "lung cancer." D. Describes having a "body wracking dry cough" of 6 weeks duration.

Correct Answer is D

Explanation

A) Presents with a hacking nonproductive cough of 6 weeks duration:
This documentation accurately describes the client's symptom of a cough but does not capture the client's expressed concern about the possibility of lung cancer. It is important to document the client's specific concerns and fears.

B) Expresses concern of "lung cancer" symptoms for last 6 weeks:
While this option captures the client's concern about lung cancer, it does not specifically describe the client's symptom of a dry cough. Effective documentation should include both the client's expressed concerns and the associated symptoms.

C) An adult male presents with fears that he has "lung cancer":
This option captures the client's fear of having lung cancer but does not describe the specific symptom of a dry cough that the client is experiencing. Including the specific symptom in the documentation is important for comprehensive assessment and evaluation.

D) Describes having a "body wracking dry cough" of 6 weeks duration:
This option effectively documents both the client's specific symptom (dry cough) and the duration of the symptom (6 weeks), which aligns with the client's expressed concerns. It accurately reflects the client's statement and provides valuable information for the healthcare provider's assessment and management.

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In assessing tactile fremitus in the client with suspected pneumonia, the nurse should perform which action?

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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 C

Explanation

Correct Answer is D

Explanation

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