Patient Data

Exhibits

Which can the nurse do to mitigate artifacts when performing auscultation? Select all that apply.

Wet the chest hair before auscultating

Reach under a gown to listen and take care that no clothing rubs on the stethoscope

Document the roaring and crackles

Keep the examination room warm, and warm the stethoscope

Answer and Explanation

Correct Answer : A,B,D

A. Wet the chest hair before auscultating. Chest hair can cause a "roaring" or crackling sound due to friction with the stethoscope. Wetting the hair with warm water or using a thin layer of lotion can help reduce this artifact, improving the accuracy of auscultation.

B. Reach under a gown to listen and take care that no clothing rubs on the stethoscope. Clothing can create extra noise during auscultation, leading to misleading findings. Placing the stethoscope directly on the skin helps eliminate external interference and ensures clearer lung and heart sounds.

C. Document the roaring and crackles. If the sounds are determined to be artifacts caused by external factors such as chest hair or clothing, they should not be documented as true auscultatory findings. Instead, the nurse should take steps to eliminate the artifacts before making an assessment.

D. Keep the examination room warm, and warm the stethoscope. A cold environment or a cold stethoscope can cause the patient’s muscles to tense or shiver, leading to additional noise during auscultation. Keeping the room warm and warming the stethoscope before use helps prevent these unnecessary sounds.

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Correct Answer is B

Explanation

A. Compare the range of motion of both legs. While range of motion assessment is useful in evaluating joint or neuromuscular conditions, it does not directly relate to the observed shiny skin and hair loss, which suggest circulatory insufficiency.

B. Palpate the client's dorsalis pedis pulses. Shiny skin and loss of hair on the lower legs are classic signs of peripheral arterial disease (PAD), a common complication of diabetes mellitus due to poor circulation. Checking the dorsalis pedis pulses helps assess arterial blood flow to the lower extremities.

C. Ask if the client often feels weak or hungry. Weakness or hunger could indicate hypoglycemia, but they are unrelated to vascular changes observed in this case. The focus should be on assessing circulation rather than glucose regulation at this moment.

D. Measure the client's capillary glucose. While blood sugar control is critical for diabetes management, the observed skin changes suggest vascular impairment rather than acute hyperglycemia or hypoglycemia. Circulatory assessment is the priority.

A. Record the findings in the client's record. B. Culture the white patches for possible fungal growth. C. Referral to an audiologist for a hearing evaluation. D. Clean the ears to remove excess wax build up.

Correct Answer is A

Explanation

A. Record the findings in the client's record. Dense white patches on the tympanic membrane (TM) are often due to tympanosclerosis, which results from past ear infections or previous scarring. Since the TMs are translucent gray with a normal light reflex and visible landmarks, this is a benign finding and should simply be documented.

B. Culture the white patches for possible fungal growth. Fungal infections (otomycosis) typically present with fluffy, black or white fungal debris in the ear canal, not as dense, white scarring on the TM. There is no indication of an active infection.

C. Referral to an audiologist for a hearing evaluation. Tympanosclerosis can cause hearing loss if it significantly stiffens the TM or ossicles, but the client denies hearing loss or symptoms. Routine monitoring is appropriate unless hearing issues arise.

D. Clean the ears to remove excess wax build-up. The description does not indicate wax accumulation, but rather white patches on the TM, which are not removable by cleaning. Wax is typically found in the external ear canal, not on the TM itself.

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Patient Data Exhibits Which can the nurse do to mitigate artifacts when performing auscultation? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse observes that the lower legs of a client with diabetes mellitus are shiny, and with no hair growth. To obtain additional data to support these findings, which assessment should the nurse perform?

Correct Answer is B

Explanation

Correct Answer is A

Explanation

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Patient Data

Exhibits

Which can the nurse do to mitigate artifacts when performing auscultation? Select all that apply.