A nurse is caring for a 65-year-old female client in the emergency department.

Select the landmarks that are used to find the PMI to auscultate the apical pulse.

Choice A rationale: Observing respirations for rate, rhythm, and depth is crucial in pneumonia management as respiratory compromise may develop rapidly. Changes in respiratory pattern such as tachypnea, irregular rhythm, or shallow breaths can indicate worsening lung function, hypoxia, or impending respiratory failure, requiring immediate intervention.

Choice B rationale: Inspecting skin and mucous membranes helps assess for signs of hypoxia or poor perfusion, such as cyanosis or pallor. These findings can indicate inadequate oxygen delivery due to impaired lung function in pneumonia. Monitoring skin integrity is also important for infection control and early detection of complications.

Choice C rationale: Measuring the apical pulse for 60 seconds is important in cardiac assessments, especially if arrhythmias or murmurs are suspected. However, in pneumonia without cardiac symptoms or abnormal heart sounds, continuous assessment of apical pulse is not prioritized in a focused respiratory assessment.

Choice D rationale: Auscultating the chest is essential to evaluate breath sounds for signs of consolidation, crackles, or diminished air entry, which directly reflect pneumonia severity and progression. Regular auscultation helps guide treatment decisions and detect complications like pleural effusion or pneumothorax.

Choice E rationale: Having the client demonstrate incentive spirometer use ensures proper technique, promoting lung expansion and preventing atelectasis. Correct use reduces pulmonary complications and supports recovery, making it an important part of nursing assessment and education in pneumonia care.

Choice F rationale: Determining heart rhythm is important in cardiac assessments, but in the absence of arrhythmia symptoms or abnormal ECG findings, it is not a primary focus in pneumonia care. Monitoring vital signs regularly is sufficient unless clinical indications suggest otherwise.

Choice A rationale

Whispering "one, two, three" is a technique used to assess for whispered pectoriloquy. This phenomenon occurs when whispered words are heard distinctly through the stethoscope, indicating consolidation in the lung parenchyma. While useful for identifying lung pathology, it specifically targets sound transmission of quiet speech, not the characteristic "E" to "A" sound change of egophony.

Choice B rationale

Breathing in and out during auscultation allows the nurse to listen to normal breath sounds and detect adventitious sounds like crackles, wheezes, or rhonchi, which are indicative of various respiratory conditions. However, this general breathing instruction does not specifically elicit the voice changes required to assess for egophony, which involves vocalization.

Choice C rationale

Egophony is an abnormal voice sound characterized by a nasal or bleating quality, often described as an "E" sounding like "A.”. This phenomenon occurs due to altered sound transmission through consolidated lung tissue, which acts as a filter, preferentially transmitting higher frequencies and altering vowel sounds. Instructing the client to repeat "E" allows the nurse to identify this specific acoustic change.

Choice D rationale

Repeating "99" during auscultation is the instruction given to assess for bronchophony. Bronchophony is present when spoken words are heard more loudly and clearly through the stethoscope over areas of lung consolidation, indicating enhanced sound transmission due to increased tissue density. While both egophony and bronchophony suggest consolidation, they are distinct auditory phenomena elicited by different vocalizations.