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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is B

Explanation

A) White blood cell count (WBC): While an elevated WBC count can indicate infection or inflammation, it is not directly related to melena. Melena, which is black, tarry stool, is usually an indication of gastrointestinal bleeding, specifically from the upper GI tract.

B) Hematocrit: Hematocrit is a measure of the proportion of red blood cells in the blood. Monitoring hematocrit is essential in the context of melena because gastrointestinal bleeding can lead to a decrease in red blood cells, causing anemia. Therefore, tracking hematocrit levels helps assess the severity of blood loss and the client's overall oxygen-carrying capacity.

C) Glucose: Blood glucose levels are not directly related to melena. Monitoring glucose is crucial for managing diabetes and other metabolic disorders but does not provide information about bleeding or anemia.

D) Blood urea nitrogen (BUN): While BUN levels can increase with gastrointestinal bleeding due to the breakdown of blood proteins in the gut, it is not the primary test to monitor for the effects of bleeding. Hematocrit is more directly indicative of blood loss.

A. Abduct each hip while the client is supine. B. Flex the hip and knee while standing. C. Observe balance while the client stands. D. Inspect gluteal folds for symmetry.

Correct Answer is B

Explanation

A) Abduct each hip while the client is supine:
While assessing hip abduction can provide information about hip joint mobility, it may not be the most appropriate initial assessment for hip dysfunction. This action primarily evaluates the range of motion but may not specifically target dysfunction in the hip region.

B) Flex the hip and knee while standing:
Flexing the hip and knee while the client is standing can help assess hip function, particularly in weight-bearing positions. This action can reveal limitations in hip mobility and detect dysfunction such as pain or weakness during movement.

C) Observe balance while the client stands:
Observing balance while the client stands is important for assessing overall lower extremity function, including the hips. However, it may not specifically target dysfunction in the hip region and may provide more general information about mobility and stability.

D) Inspect gluteal folds for symmetry:
Inspecting gluteal folds for symmetry can help identify asymmetry or abnormalities in the hip region, but it may not provide direct information about hip dysfunction. This action is more focused on assessing external appearance rather than functional movement or mobility.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

The nurse observes that a client is experiencing melena. Which serum laboratory test should the nurse monitor in response to this finding?

Correct Answer is B

Explanation

The nurse is examining an older female client and suspects that she has a dysfunction in her hip region. Which procedure should the nurse perform to further assess for hip dysfunction?

Correct Answer is B

Explanation

The nurse applies pressure over an area of the lower abdomen where the client reports pain. The client denies pain upon palpation, but reports pain when the pressure is released. Which action should the nurse implement?

During the admission assessment, a client admitted with chest pain reports having no breathing problems and no trouble sleeping at night. To obtain further data regarding possible orthopnea, which action should the nurse take?

While performing a physical assessment, the nurse is unable to palpate the client's pedal pulses. Which action should the nurse take?

The nurse is performing an admission assessment for a client with pyelonephritis who has urgency and burning while urinating. Which finding indicates an expected response when the nurse percusses the costovertebral angle?

While interviewing a newly admitted older female client, the nurse observes that the client ignores questions asked by the nurse, and speaks loudly to her son who brought her to the hospital. Which action should the nurse implement first?

To objectively confirm the presence of fever, before taking the client's temperature, which action should the nurse take?

When inspecting the client's skin, the nurse observes several areas of ecchymosis on the trunk and extremities. Which information in the client's history requires additional follow-up by the nurse?