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

Aortic site.

Sternum.

Lung apex.

Clavicle.

Answer and Explanation

The Correct Answer is C

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.

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Correct Answer is B

Explanation

B. Cardiac enlargement:
This is the most likely interpretation of the findings. A significant area of dullness across a larger portion of the chest, as described, suggests that the heart is enlarged (cardiomegaly). Enlargement of the heart may result from various conditions, such as heart failure, hypertension, or valvular disease, leading to increased cardiac size and the shift in the percussion borders. This could indicate that the heart has expanded beyond its normal anatomical limits, and further assessment, such as imaging, would be necessary to confirm the diagnosis.

A. Left carotid artery has strong pulse; right carotid artery occluded. B. Left carotid pulse volume of 4+; right carotid pulse volume of 0. C. Left carotid artery occlusion present; no occlusion of right carotid artery. D. Left carotid artery bruit present; no bruit heard in right carotid artery.

Correct Answer is D

Explanation

A) Left carotid artery has strong pulse; right carotid artery occluded:
This documentation is incorrect because the presence of a bruit does not indicate a strong pulse or occlusion. A bruit suggests turbulent blood flow, often due to partial obstruction or narrowing of the artery, not necessarily a strong pulse or complete occlusion.

B) Left carotid pulse volume of 4+; right carotid pulse volume of 0:
This documentation focuses on the pulse volume rather than the presence of a bruit. The nurse's assessment was related to auscultation findings (bruit) rather than palpation findings (pulse volume).

C) Left carotid artery occlusion present; no occlusion of right carotid artery:
A bruit indicates turbulent blood flow, which may be due to partial obstruction, but it does not confirm complete occlusion. Therefore, this documentation would be inaccurate.

D) Left carotid artery bruit present; no bruit heard in right carotid artery:
This documentation accurately reflects the nurse's findings. A bruit is a blowing, swishing sound indicating turbulent blood flow, often due to narrowing or partial obstruction of the artery. Documenting the presence of a bruit provides essential information for further evaluation and management.

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

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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