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 D

Explanation

A. Tertiary care Tertiary care refers to specialized medical care provided in hospitals for complex conditions (e.g., ICU care, cancer treatment, neurosurgery). It is not a self-care resource for caregivers.
B. Restorative care Restorative care focuses on rehabilitation and regaining function (e.g., physical therapy, speech therapy) rather than providing relief for caregivers.
C. Telemedicine care Telemedicine involves remote medical consultations, which can benefit clients but does not specifically address caregiver self-care needs.
D. Respite care Respite care provides temporary relief for caregivers by arranging for short-term professional care of their loved ones. This helps prevent caregiver burnout and supports self-care for those providing long-term assistance.

A. A fire extinguisher is kept in the kitchen. B. An electrical ground plug is present. C. The client's oxygen tanks are stored on their side. D. The client's walking cane has a rubber tip.

Correct Answer is C

Explanation

A. A fire extinguisher is kept in the kitchen This is a safe and recommended practice, as the kitchen is a common area where fires may occur.
B. An electrical ground plug is present Ground plugs help prevent electrical shock and ensure safety, so no intervention is needed.
C. The client's oxygen tanks are stored on their side Oxygen tanks should always be stored upright and secured to prevent leaks or potential combustion. Storing them on their side increases the risk of damage to the tank or regulator, which can be hazardous.
D. The client's walking cane has a rubber tip A rubber tip provides stability and prevents slipping, making it a safe practice.

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