A nurse is assessing the breath sounds of an adult client who has pneumonia. Which of the following actions should the nurse take?
Place the bell of the stethoscope on the client's chest.
Follow a systematic pattern from side-to-side moving down the client's chest.
Ask the client to breathe in deeply through his nose.
Instruct the client to sit erect with their head tilted slightly backward.
The Correct Answer is B
A. "Place the bell of the stethoscope on the client's chest." The diaphragm of the stethoscope, not the bell, should be used to auscultate breath sounds because it is designed for high-pitched sounds like lung sounds.
B. "Follow a systematic pattern from side-to-side moving down the client's chest." To accurately compare breath sounds bilaterally, the nurse should use a side-to-side pattern, moving down the chest and back. This ensures a proper assessment of any asymmetry or abnormal sounds.
C. "Ask the client to breathe in deeply through his nose." The client should be instructed to breathe deeply through their mouth, not their nose, to enhance the clarity of breath sounds.
D. "Instruct the client to sit erect with their head tilted slightly backward." The ideal position for auscultating lung sounds is sitting upright with shoulders relaxed and slightly forward, allowing full lung expansion. Tilting the head backward is unnecessary.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "A narrow base of support is recommended for effective lifting." A wide base of support provides more stability and balance, reducing the risk of injury.
B. "Make sure to bend at the waist when lifting objects more than 30 pounds." Bending at the knees, not the waist, helps maintain a neutral spine and prevents back strain.
C. "Use a twisting motion when moving objects to prevent back strain." Twisting while lifting can cause spinal injuries; instead, move the entire body by pivoting the feet.
D. "Stand close to a heavy object before attempting to lift it." Standing close to the object reduces strain on the back and improves control during lifting.
Correct Answer is D
Explanation
A. "I should close all doors and windows on the unit." –
This action is part of the "C" (Confine) step, which should be done before attempting to extinguish the fire.
B. "I should evacuate clients who are in immediate danger." –
Rescuing clients is the first step and should be done immediately.
C. "I should activate the facility's fire alarm system." –
Activating the alarm is the second step after rescuing clients.
D. "I should extinguish small fires if it is safe to do so." –
Extinguishing the fire is the last action in the fire safety protocol and should only be attempted if the fire is small and controllable.
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