A nurse is auscultating the lungs of a client and hears low-pitched, soft breath sounds over the posterior lower lobes and inspiration that is longer than expiration. How should the nurse interpret these findings?

These sounds are normally auscultated over the trachea

These are bronchial breath sounds and normal in that location

These are bronchovesicular breath sounds and normal in that location

These are vesicular breath sounds and normal in that location

Answer and Explanation

The Correct Answer is D

A) These sounds are normally auscultated over the trachea:
This is incorrect. The tracheal breath sounds are harsh, loud, and high-pitched, typically heard over the trachea and larynx. These characteristics differ from the soft, low-pitched sounds described in the question, which are more consistent with vesicular breath sounds.

B) These are bronchial breath sounds and normal in that location:
This is incorrect. Bronchial breath sounds are typically heard over the trachea and larynx, not the lower lobes of the lungs. Bronchial sounds are loud, high-pitched, and have a longer expiration phase compared to inspiration, unlike the low-pitched, soft sounds with longer inspiration that are heard in the lower lobes.

C) These are bronchovesicular breath sounds and normal in that location:
This is incorrect. Bronchovesicular breath sounds are a mix of bronchial and vesicular sounds, with inspiration and expiration of about equal duration. They are typically heard over the major bronchi, near the sternum and between the scapulae, rather than over the posterior lower lobes. The description in the question suggests vesicular breath sounds, which have a longer inspiration phase.

D) These are vesicular breath sounds and normal in that location:
This is the correct answer. Vesicular breath sounds are soft, low-pitched, and typically heard over the peripheral lung fields, including the posterior lower lobes. These sounds have a longer inspiration phase than expiration and are considered normal in this location. The description in the question fits the characteristics of vesicular breath sounds perfectly.

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Correct Answer is ["B","C","E"]

Explanation

A) Client's oral temperature is 38.4°C (101.2°F):
This is objective data, as it is a measurable, observable finding obtained through direct assessment (in this case, using a thermometer). Objective data are facts or measurements that can be verified or observed by the healthcare provider.

B) Client reports the rash on their back is itchy:
This is subjective data, as it is based on the client's personal experience and report. The feeling of itchiness cannot be directly measured or observed by the nurse; it is something the client experiences and describes. Subjective data include symptoms, sensations, or feelings reported by the client.

C) Client reports nausea following administration of pain medication:
This is subjective data. Nausea is a symptom that the client reports experiencing, which cannot be objectively measured or directly observed by the nurse. It is based on the client's perception and report, making it subjective.

D) Client has a vesicular rash on their upper back:
This is objective data. The rash is something the nurse can observe and describe. Objective data include observable facts, such as physical exam findings, lab results, or diagnostic test results.

E) Client reports dull, aching pain in lower right calf:
This is subjective data, as pain is a sensation that the client experiences and describes. The intensity, location, and type of pain (dull, aching) are subjective experiences that only the client can report.

A. The best time to perform BSE is immediately prior to the menstrual cycle B. If pregnancy is suspected, BSE should not be performed until post delivery C. The best time to perform BSE is 4 to 7 days after the first day of the menstrual period D. The woman with diagnosed fibrocystic breast tissue should not rely on BSE

Correct Answer is C

Explanation

A) The best time to perform BSE is immediately prior to the menstrual cycle:
Performing a breast self-examination (BSE) immediately prior to the menstrual cycle is not ideal because hormonal changes leading up to menstruation can cause the breasts to become swollen, tender, and lumpy. These changes could make it difficult to detect subtle lumps or changes in the breast tissue. For the most accurate assessment, it's recommended that women avoid performing BSE during the premenstrual phase when the breast tissue is most likely to be affected by hormonal fluctuations.

B) If pregnancy is suspected, BSE should not be performed until post-delivery:
This statement is incorrect. There is no contraindication to performing a breast self-examination during pregnancy, and it is important for pregnant women to continue self-monitoring for any changes in breast tissue. In fact, BSE should be performed regularly during pregnancy, as the breast tissue can undergo changes due to hormonal shifts, and early detection of any abnormalities is key to successful management.

C) The best time to perform BSE is 4 to 7 days after the first day of the menstrual period:
This is the correct recommendation. The best time to perform a BSE is 4 to 7 days after the first day of the menstrual period because the breasts are least likely to be swollen or tender during this time. Hormonal levels are more stable at this point in the menstrual cycle, and any lumps or changes in the tissue are more likely to be noticeable. Performing BSE during this time increases the likelihood of detecting potential abnormalities.

D) The woman with diagnosed fibrocystic breast tissue should not rely on BSE:
While it is true that women with fibrocystic breast changes may experience lumpy, tender tissue, they should still perform BSE regularly. Fibrocystic tissue can sometimes make it more difficult to distinguish between normal and abnormal changes, but BSE remains an important tool for detecting significant changes, such as new lumps or changes in size, shape, or consistency. Women with fibrocystic breast tissue should be taught to perform BSE regularly and to report any unusual changes to their healthcare provider. Relying solely on BSE for breast cancer detection is not recommended, but it is an essential part of breast health awareness.

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A nurse is auscultating the lungs of a client and hears low-pitched, soft breath sounds over the posterior lower lobes and inspiration that is longer than expiration. How should the nurse interpret these findings?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is documenting assessment findings on a client. Which of the following entries should the nurse identify as subjective data? (Select All that Apply.)

Correct Answer is ["B","C","E"]

Explanation

A nurse is conducting a class on Breast Self-Examination (BSE) for women of childbearing age. The nurse should include which of these statements that indicates the proper BSE technique?

Correct Answer is C

Explanation

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