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. "Do you have difficulty sleeping at night?" – While sleep disturbances are common in PTSD, this question assesses symptoms rather than support systems.
B. "How do you feel about the current status of your life?" – This question may provide insight into the client’s emotional state but does not directly assess their support systems.
C. "Have you noticed changes in your eating patterns?" – Changes in appetite can occur with PTSD, but this question focuses on physical symptoms rather than support systems.
D. "Are you comfortable discussing the disaster with your family or friends?" – This is the best choice because it directly assesses whether the client has a support system in place and feels comfortable relying on them for emotional support.
Correct Answer is ["A","B","C"]
Explanation
Client is difficult to arouse – This is concerning and may indicate opioid overdose or sedation due to the recent administration of morphine. The nurse should assess the client's level of consciousness closely and consider reversal of the opioid (naloxone) if the client's level of sedation is excessive.
Respiratory rate 10/min – This is below the normal respiratory rate (12–20 breaths/min) and could indicate respiratory depression, a common side effect of opioids like morphine. Close monitoring and possible intervention are required.
Pulse oximetry 88% on room air (95% to 100%) – The oxygen saturation is low, which could indicate hypoxemia. The nurse should administer supplemental oxygen and notify the provider.
Other Findings:
Pupils are 3 mm, equal, and reactive to light – This is a normal finding and not concerning for opioid overdose.
Blood pressure 99/46 mm Hg – This is slightly lower than normal but not critically low, considering the client's condition. Morphine can cause hypotension, especially in older adults or hypovolemic clients.
Heart rate 61/min – This is within a normal range for some postoperative patients, especially in a restful state.
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