During auscultation of breath sounds, the nurse should correctly use the stethoscope in which of the following ways?
Listening as the patient inhales and then going to the next site during exhalation
If the patient is modest, listening to sounds over his or her clothing or hospital gown.
Instructing the patient to breathe in and out rapidly while listening to the breath sounds
Listening to at least one full respiration in each location
The Correct Answer is D
A. Listening as the patient inhales and then going to the next site during exhalation. This method does not allow for a complete assessment of breath sounds, as abnormalities may be present during either phase of respiration.
B. If the patient is modest, listening to sounds over his or her clothing or hospital gown. Clothing can muffle or distort breath sounds, leading to inaccurate assessments. The stethoscope should be placed directly on the skin.
C. Instructing the patient to breathe in and out rapidly while listening to the breath sounds. Rapid breathing may lead to hyperventilation and dizziness, and it can make it difficult to detect subtle abnormalities such as crackles or wheezes.
D. Listening to at least one full respiration in each location. This is the correct technique because it allows the nurse to fully assess breath sounds during both inhalation and exhalation, ensuring accurate identification of any abnormal sounds.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Inform the patient's health care provider immediately to obtain an order for antihypertensive medications. While notifying the provider may be necessary, the nurse must first confirm the accuracy of the blood pressure reading before taking further action.
B. Instruct the nursing assistant to take the patient's blood pressure again and inform the nurse of the results immediately. Nursing assistants can take blood pressure readings, but the nurse should personally verify a critically high reading using a manual method.
C. Take the patient's blood pressure manually with a sphygmomanometer and stethoscope. Electronic monitors can sometimes give false readings, especially in patients with irregular heartbeats or movement. Manually verifying ensures an accurate assessment before determining further action.
D. Perform a neurological assessment to determine if the patient is stressed, in pain, or having a stroke. A neurological assessment is important if the elevated BP is confirmed, but the first priority is verifying the reading manually.
Correct Answer is D
Explanation
A. Perception occurs when the brain interprets pain signals and recognizes them as pain. This step happens after the nerve impulses have been transmitted to the brain.
B. Transduction is the first step in the pain process, where painful stimuli (such as cutting a finger) activate nociceptors, converting the stimulus into an electrical signal.
C. Modulation involves the body’s response to pain signals, where descending nerve pathways release substances like endorphins to inhibit pain transmission. This occurs later in the pain process.
D. Transmission is the process of pain signals traveling from the site of injury to the spinal cord and brain via afferent nerve fibers. This step occurs after transduction and allows pain signals to reach the central nervous system.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.