A nurse is assessing a client for tactile fremitus. The nurse should recognize that it is normal to feel tactile fremitus most intensely over which location?

Fifth intercostal space, midaxillary line

Between the scapulae

Third intercostal space, midaxillary line

Over the lobes, posterior side

Answer and Explanation

The Correct Answer is B

A) Fifth intercostal space, midaxillary line:
This is incorrect. The fifth intercostal space at the midaxillary line is a location that can be assessed for tactile fremitus, but it is not typically where fremitus is felt most intensely. Fremitus tends to be stronger near the midline structures, such as over the trachea, rather than at this lateral position, which is more peripheral.

B) Between the scapulae:
This is the correct answer. Tactile fremitus is usually most intense over the area between the scapulae and near the sternum. This is because the bronchi and trachea are located close to the chest wall in these regions, creating more intense vibrations that can be palpated during assessment. The fremitus is transmitted through the airways and is easiest to feel when the lung tissue is close to the chest wall, as in the area between the scapulae.

C) Third intercostal space, midaxillary line:
This is incorrect. The third intercostal space at the midaxillary line is not typically the site where tactile fremitus is most prominent. This area is more peripheral, and fremitus tends to be weaker here compared to regions closer to the sternum or between the scapulae where the lungs are nearer to the chest wall.

D) Over the lobes, posterior side:
This is incorrect. While tactile fremitus can be assessed over the posterior lobes of the lungs, it is not generally felt most intensely here. Fremitus is usually stronger near the midline of the chest (sternum) or between the scapulae, and tends to be weaker as you move laterally or toward the lower lobes of the lungs.

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Correct Answer is D

Explanation

A) Tactile fremitus:
Tactile fremitus refers to the vibrations felt on the chest wall when a patient speaks. It is assessed by placing the hands on the chest while the patient says "ninety-nine" or a similar phrase. Tactile fremitus is used to detect changes in lung density, such as consolidation or fluid. It does not describe a crackling sensation on the skin surface. A coarse, crackling sensation is more indicative of a different condition.

B) Adventitious sounds:
Adventitious sounds are abnormal lung sounds, such as crackles, wheezes, or rhonchi, heard during auscultation. These sounds are typically related to lung conditions, such as pneumonia, asthma, or fluid accumulation in the lungs. While adventitious sounds are significant findings during auscultation, they do not describe the physical sensation of crackling felt on the skin surface. Therefore, adventitious sounds are not the correct diagnosis for a tactile sensation over the chest.

C) Friction rub:
A friction rub is a harsh, grating sound heard during auscultation and is caused by inflammation of the pleura (the lining around the lungs). It occurs when the inflamed pleural surfaces rub together during breathing. While it is a distinct sound, a friction rub is not a tactile or palpable sensation. The crackling sensation described in the question is not related to the sounds produced by a pleural friction rub.

D) Crepitus:
Crepitus is the correct answer. It refers to a coarse, crackling sensation felt on the skin surface when air or gas is trapped under the skin, often due to conditions such as subcutaneous emphysema. This can occur when there is air leaking from the lungs or other parts of the respiratory system, often following trauma (e.g., rib fractures or surgery) or infection (e.g., gas gangrene). The crackling sensation felt during palpation of the chest wall is characteristic of crepitus, making this the most appropriate finding in this scenario.

A. Whisper random numbers letters, then have the client repeat them B. Shield the lips so that the sound is muffled C. Stand approximately 4 feet away from the client D. Have the client place a finger in the ear canal to occlude outside noise

Correct Answer is A

Explanation

A) Whisper random numbers and letters, then have the client repeat them:
This is correct. The voice test is a simple way to assess a client's hearing. The nurse should stand about 2 feet away from the client and whisper random numbers or letters. The client should repeat what they hear. This test checks the ability to hear and distinguish sounds, particularly for high-frequency tones. It's an effective screening method for detecting hearing loss.

B) Shield the lips so that the sound is muffled:
This is incorrect. The nurse should not shield their lips during the voice test because it could interfere with the client's ability to hear and potentially read the nurse's lips, which can help with understanding. The client should be allowed to observe lip movements to aid in comprehension of the sounds being spoken.

C) Stand approximately 4 feet away from the client:
This is incorrect. The recommended distance for performing the voice test is typically around 2 feet, not 4 feet. Standing too far away can make it more difficult for the client to hear the whispered numbers or letters and could affect the accuracy of the test. The nurse should stand close enough (about 2 feet) to ensure that the sound is audible to the client but not too close as to distort the test.

D) Have the client place a finger in the ear canal to occlude outside noise:
This is incorrect. While the client should be instructed to avoid distractions or loud environments during the test, placing a finger in the ear canal is not necessary. The test assesses the client's ability to hear sound, and occluding the ear could affect the results. The client should simply be in a quiet environment.

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A nurse is assessing a client for tactile fremitus. The nurse should recognize that it is normal to feel tactile fremitus most intensely over which location?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is palpating a client's anterior chest wall and notices a course, crackling sensation over the skin surface. Which of the following should the nurse suspect from these findings?

Correct Answer is D

Explanation

A nurse is performing a voice test to assess a client's hearing. Which of these actions should the nurse perform?

Correct Answer is A

Explanation

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