A newly admitted patient is in acute pain, has not been sleeping well lately, and is having difficulty breathing. How should the nurse prioritize these problems?

Breathing, pain, and sleep.

Breathing, sleep, and pain.

Sleep, breathing, and pain.

Sleep, pain, and breathing.

Answer and Explanation

The Correct Answer is A

Choice A reason: Breathing difficulty is the highest priority, as it affects oxygenation, a life-threatening issue. Pain is next, impacting comfort and recovery, followed by sleep, which supports healing. This follows the ABC (Airway, Breathing, Circulation) prioritization, making it the correct order for addressing the patient’s issues.

Choice B reason: Prioritizing sleep over pain after breathing is incorrect; pain is more urgent, as it distresses and affects recovery, while sleep is secondary. Breathing remains first, but pain precedes sleep, so this is incorrect for prioritization.

Choice C reason: Sleep as the first priority ignores breathing, a critical life-threatening issue. Breathing and pain are more urgent, with sleep supporting long-term recovery, so this is incorrect for acute care prioritization principles.

Choice D reason: Placing sleep first and breathing last disregards life-threatening breathing issues. Breathing, then pain, then sleep align with ABC priorities, ensuring patient patient safety, so this is incorrect for the nurse’s approach.

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Correct Answer is C

Explanation

Choice A reason: The right 5th intercostal space at the sternal border is near the tricuspid valve, where murmurs from tricuspid regurgitation or stenosis are typically heard. Aortic valve stenosis murmurs, caused by turbulent flow through a narrowed aortic valve, are not prominent here, making this an incorrect assessment site.

Choice B reason: The right 2nd intercostal space at the sternal border is the aortic area, ideal for auscultating aortic valve stenosis murmurs. These murmurs are harsh, crescendo-decrescendo, and systolic, radiating to the carotid arteries due to turbulent blood flow through the stenosed aortic valve, making this the correct site.

Choice C reason: The left 5th intercostal space at the mid-clavicular line is the mitral valve area, where mitral regurgitation or stenosis murmurs are heard. Aortic valve stenosis murmurs originate from the aortic root and are not best detected here, rendering this choice incorrect.

Choice D reason: The left 2nd intercostal space at the mid-clavicular line is near the pulmonic valve, where pulmonic stenosis murmurs are auscultated. Aortic valve stenosis murmurs are not prominent in this area, as they are specific to the aortic region, making this an incorrect choice.

A. Bronchial breath sounds that are normal in that location B. Normal sounds auscultated over the trachea C. Vesicular breath sounds that are normal in that location D. Bronchovesicular breath sounds that are normal in that location

Correct Answer is C

Explanation

Choice A reason: Bronchial breath sounds are loud, high-pitched, with expiration longer than inspiration, typically heard over the trachea or in consolidated lung areas. The described soft, low-pitched sounds with longer inspiration in the posterior lower lobes do not match, making this incorrect.

Choice B reason: Sounds over the trachea are bronchial, characterized by loud, high-pitched sounds with expiration equal to or longer than inspiration. The soft, low-pitched sounds with longer inspiration in the posterior lower lobes indicate peripheral lung fields, not tracheal sounds, making this incorrect.

Choice C reason: Vesicular breath sounds are soft, low-pitched, with inspiration longer than expiration, heard over peripheral lung fields like the posterior lower lobes. These are normal findings, reflecting air movement in alveoli, making this the correct interpretation of the described sounds.

Choice D reason: Bronchovesicular sounds are medium-pitched with equal inspiration and expiration, typically heard near mainstem bronchi. The described low-pitched sounds with longer inspiration in the posterior lower lobes align with vesicular sounds, not bronchovesicular, making this incorrect.

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A newly admitted patient is in acute pain, has not been sleeping well lately, and is having difficulty breathing. How should the nurse prioritize these problems?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which area would the nurse assess for a murmur due to aortic valve stenosis?

Correct Answer is C

Explanation

When auscultating the lungs of an adult patient, the nurse notes that low-pitched, soft breath sounds are heard over the posterior lower lobes, with inspiration being longer than expiration. How should the nurse interpret these findings?

Correct Answer is C

Explanation

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