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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Place multiple smoke detectors in the same area of the home. Smoke detectors should be placed in different areas, especially near bedrooms, in hallways, and on every level of the home, rather than clustering them in one area.
B. Change the batteries in smoke detectors every 2 years. Batteries should be changed at least once a year, and the smoke detector should be tested monthly to ensure functionality.
C. Cover the nose and mouth with a damp cloth before exiting a smoke-filled area. Using a damp cloth helps filter out some smoke and toxic fumes, reducing inhalation of harmful particles.
D. Open a window to let smoke out before leaving the home. Opening a window can increase oxygen flow, which may intensify the fire rather than help in an evacuation. Instead, the priority should be to evacuate immediately and call emergency services.

A. A client was placed in the waiting room based on their triage assessment. B. A client was transferred to the inpatient antepartum unit to rule out preterm labor. C. A client was referred to the county hospital for medical screening evaluation. D. A stable client was transferred to a public hospital that provides reduced-cost care.

Correct Answer is C

Explanation

A. "A client was placed in the waiting room based on their triage assessment." Hospitals can prioritize clients based on triage assessment as long as they receive a medical screening examination and stabilizing treatment if necessary.
B. "A client was transferred to the inpatient antepartum unit to rule out preterm labor." EMTALA requires that hospitals evaluate and stabilize clients with emergency medical conditions, including preterm labor. Transferring a client within the same facility for further evaluation does not violate EMTALA.
C. "A client was referred to the county hospital for medical screening evaluation." Under EMTALA, hospitals must provide a medical screening examination and necessary stabilizing treatment before referring or transferring a client, regardless of their insurance status. Sending a client elsewhere for evaluation without treatment is a violation.
D. "A stable client was transferred to a public hospital that provides reduced-cost care." Once a client has been stabilized, hospitals may arrange for transfer to another facility, provided the transfer meets EMTALA guidelines and is in the client's best interest.

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A nurse is assessing the breath sounds of an adult client who has pneumonia. Which of the following actions should the nurse take?

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