While auscultating a client's breath sounds, the nurse hears vesicular sounds in the bases of both lungs posteriorly. Which action should the nurse take in response to this finding?

Continue with the remainder of the client's physical assessment.

Report the client's abnormal lung sounds to the healthcare provider.

Ask the client to cough and then auscultate at the site again.

Measure the client's oxygen saturation with a pulse oximeter.

Answer and Explanation

The Correct Answer is A

A) Continue with the remainder of the client's physical assessment:
Vesicular breath sounds are normal breath sounds heard over the peripheral lung fields. Hearing vesicular sounds in the bases of both lungs posteriorly indicates normal air movement in the lungs. Therefore, there is no immediate concern or need for further action related to this finding. The nurse should continue with the remainder of the client's physical assessment.

B) Report the client's abnormal lung sounds to the healthcare provider:
Vesicular breath sounds are considered normal lung sounds and do not warrant reporting as abnormal. Reporting this finding to the healthcare provider would not be appropriate and may lead to unnecessary concern or intervention.

C) Ask the client to cough and then auscultate at the site again:
Coughing would not be necessary in response to hearing vesicular breath sounds, as these are normal lung sounds. Repeating the auscultation may not provide additional information beyond confirming the presence of normal breath sounds.

D) Measure the client's oxygen saturation with a pulse oximeter:
Measuring oxygen saturation with a pulse oximeter is not indicated in response to hearing vesicular breath sounds. These breath sounds are normal and do not necessarily indicate a problem with oxygenation. Therefore, measuring oxygen saturation would not be the appropriate action in this situation.

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Correct Answer is D

Explanation

A) Observe for jugular vein distention while the client is flat in bed: While jugular vein distention can indicate fluid overload or heart failure, it is not a direct assessment of orthopnea, which is the difficulty breathing while lying flat.

B) Measure the blood pressure when the client is lying and standing: This action assesses for orthostatic hypotension, which is a drop in blood pressure upon standing. While orthostatic hypotension can contribute to symptoms of dizziness or fainting upon assuming an upright position, it does not directly assess orthopnea.

C) Auscultate breath sounds while the client is supine: Auscultating breath sounds while the client is supine can provide information about lung function and the presence of abnormal breath sounds, but it does not specifically address orthopnea.

D) Ask the client how many pillows are used to sleep on at night: Orthopnea is a condition in which individuals have difficulty breathing while lying flat and may need to sleep with multiple pillows or in a more upright position to alleviate symptoms. Therefore, asking the client about the number of pillows used for sleep can provide valuable information about the presence and severity of orthopnea.

A. Looking at the client from the side, observe the size and shape of the chest wall. B. Use the fingertips to compress tissue over the lungs for evidence of a crackling sensation. C. Place the palm of the hand on the chest wall to feel vibrations while the client speaks. D. Use a stethoscope to listen to and compare breath sounds anteriorly and posteriorly.

Correct Answer is C

Explanation

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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While auscultating a client's breath sounds, the nurse hears vesicular sounds in the bases of both lungs posteriorly. Which action should the nurse take in response to this finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is C

Explanation

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