A male client arrives at the clinic for follow-up health assessment after recent antibiotic treatment for pneumonia without hospitalization. Which technique should the nurse implement to assess for adventitious lung sounds?

Have the client lay flat while listening to the anterior surface of the chest.

Use the bell of the stethoscope to listen to the lung fields over lower lobes.

Shave all chest hair that may distort sounds heard through the diaphragm.

Press the stethoscope's diaphragm firmly on the skin over each lung field.

Answer and Explanation

The Correct Answer is D

Choice A Reason:
Having the client lay flat while listening to the anterior surface of the chest is incorrect because having the client lay flat may not be the most optimal position for auscultating lung sounds. While auscultation of the anterior surface of the chest is important, particularly for assessing the upper lobes of the lungs, having the client lay flat may not provide the best positioning for detecting all lung sounds, especially those located in the posterior lung fields.
Choice B Reason:
Using the bell of the stethoscope to listen to the lung fields over lower lobes is incorrect because using the bell of the stethoscope is more suitable for detecting low-frequency sounds such as heart murmurs or bruits. Adventitious lung sounds, such as crackles (rales) or wheezes, are typically high-pitched sounds that are best heard using the diaphragm of the stethoscope. Therefore, using the bell may not be the most effective technique for assessing adventitious lung sounds.
Choice C Reason:
Shaving all chest hair that may distort sounds heard through the diaphragm is incorrect because while removing chest hair may improve sound transmission for certain auscultatory findings, such as heart sounds, it is not specifically indicated for assessing adventitious lung sounds. Chest hair removal is not necessary for auscultation of lung sounds with the diaphragm of the stethoscope, as the sound transmission through chest hair is minimal and unlikely to significantly distort lung sounds.
Choice D Reason:
Pressing the stethoscope's diaphragm firmly on the skin over each lung field is correct because using the diaphragm of the stethoscope and pressing it firmly on the skin over each lung field ensures good contact with the chest wall, allowing for optimal transmission of lung sounds. Adventitious lung sounds, such as crackles or wheezes, are best heard using the diaphragm, particularly when it is applied firmly to the chest wall to minimize external noise and enhance sound transmission. Therefore, this technique is the most appropriate for assessing adventitious lung sounds during auscultation.

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Correct Answer is C

Explanation

Choice A Reason:
Excoriation is incorrect. Excoriation refers to scratch marks or abrasions on the skin caused by scratching or rubbing. While excoriation can occur as a result of scratching due to itching caused by an allergic reaction, it is not a specific characteristic of an allergic reaction to an insect bite. However, it may develop secondary to the itching associated with insect bites.
Choice B Reason:
Papules are incorrect. Papules are small, raised bumps on the skin that can have various causes, including insect bites. While papules can sometimes accompany an allergic reaction to insect bites, they are not as characteristic as wheals (hives) in such reactions. Papules may also represent other skin conditions or reactions, so they are not as specific to allergic reactions as wheals.
Choice C Reason:
Wheals are correct. Wheals, also known as hives or urticaria, are raised, red, itchy areas of the skin that often occur as part of an allergic reaction to insect bites, medications, foods, or other allergens. Wheals are typically transient and can vary in size and shape. Excoriation (choice A) refers to scratch marks or abrasions on the skin caused by scratching or rubbing.
Choice D Reason:
Fissuring is incorrect. Fissuring refers to deep cracks or splits in the skin's surface. Fissures are not typically associated with allergic reactions to insect bites. Instead, they may occur in conditions such as eczema, psoriasis, or severe dry skin. Therefore, while skin fissuring may occur in some skin conditions, it is not a typical finding in allergic reactions to insect bites.

A. Hyperactive bowel sounds. B. A minor variation. C. Normal borborygmic sounds. D. Possible renal artery stenosis.

Correct Answer is D

Explanation

Choice A Reason:
Hyperactive bowel sounds are incorrect. Hyperactive bowel sounds refer to increased or loud gurgling noises heard during auscultation of the abdomen, which may indicate increased intestinal motility or bowel obstruction. These sounds are typically high-pitched and occur in various abdominal quadrants, rather than specifically in the upper midline area.
Choice B Reason:
A minor variation is incorrect. A minor variation in abdominal sounds may occur and could be considered normal. However, a low-pitched blowing sound in the upper midline area is not typically categorized as a minor variation but rather as an abnormal finding that warrants further investigation.
Choice C Reason:
Normal borborygmic sounds is incorrect. Borborygmic refers to the normal rumbling or gurgling sounds produced by the movement of gas and fluid in the intestines. While borborygmic sounds may be heard during abdominal auscultation, they are typically described as high-pitched and occur in various abdominal quadrants, not specifically in the upper midline area. Therefore, they are not likely to be the indication of the finding described in the scenario.
Choice D Reason:
Possible renal artery stenosis is correct. Renal artery stenosis is a condition characterized by the narrowing of one or both renal arteries, which can lead to reduced blood flow to the kidneys. When auscultating the abdomen, a low-pitched blowing sound (bruit) heard over the upper midline area could indicate turbulence of blood flow in the renal arteries. This bruit is typically associated with renal artery stenosis and reflects the increased velocity of blood passing through a narrowed arterial lumen. Identifying a renal artery bruit during abdominal auscultation warrants further investigation, such as imaging studies or referral to a specialist for evaluation and management of renal artery stenosis.

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A male client arrives at the clinic for follow-up health assessment after recent antibiotic treatment for pneumonia without hospitalization. Which technique should the nurse implement to assess for adventitious lung sounds?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is D

Explanation

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