During the admission assessment, a male client admitted with chest pain states he has no breathing problems and no trouble sleeping at night. To obtain further data regarding possible orthopnea, which action should the nurse take?

Observe for jugular vein distention while the client is flat in bed.

Measure the client's blood pressure when he is lying and standing.

Ask the client how many pillows he sleeps on at night.

Auscultate the client's breath sounds while he is supine.

Answer and Explanation

The Correct Answer is C

Choice A Reason:
Observing for jugular vein distention while the client is flat in bed is incorrect because jugular vein distention is not directly related to orthopnea. Jugular vein distention may indicate increased central venous pressure, which can occur in conditions such as heart failure, but it is not specific to orthopnea, which is difficulty breathing while lying flat.
Choice B Reason:
Measuring the client's blood pressure when he is lying and standing is incorrect because measuring blood pressure in different positions (lying and standing) is used to assess for orthostatic hypotension, not orthopnea. Orthostatic hypotension refers to a drop-in blood pressure upon standing and is not directly related to difficulty breathing while lying flat.
Choice C Reason:
Asking the client how many pillows he sleeps on at night is correct because orthopnea is characterized by difficulty breathing while lying flat, often relieved by sitting up or propping oneself with pillows. Asking the client how many pillows he sleeps on at night provides valuable information about his sleeping position and potential orthopnea. Clients with orthopnea often need to sleep in a semi-upright position or with multiple pillows to alleviate breathing difficulties.
Choice D Reason:
Auscultating the client's breath sounds while he is supine is incorrect because auscultating the client's breath sounds while he is supine may provide information about lung sounds, but it does not specifically assess for orthopnea. Orthopnea refers to difficulty breathing while lying flat, and the assessment of breath sounds may not directly indicate this condition.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A Reason:
Epigastric region is correct. The epigastric region is the area of the abdomen located between the lower part of the ribcage and the navel (umbilicus). Pain localized in the middle section of the abdomen below the xiphoid process corresponds to the epigastric region. This region encompasses the upper part of the stomach and the lower part of the esophagus, making it a common location for discomfort related to conditions such as gastritis, peptic ulcer disease, or gastroesophageal reflux disease (GERD).
Choice B Reason:
Hypogastric region is incorrect. The hypogastric region is located in the lower part of the abdomen, below the umbilical region. Pain in the hypogastric region typically corresponds to the lower abdomen, around the pubic bone, and may be associated with conditions such as bladder infections, menstrual cramps, or pelvic inflammatory disease.
Choice C Reason:
Hypochondriac region is incorrect. The hypochondriac regions are located on each side of the upper abdomen, beneath the ribs. Pain in the hypochondriac region may be associated with conditions affecting the liver, gallbladder, or spleen, but it does not correspond to the description provided by the client.
Choice D Reason:
Umbilical region is incorrect. The umbilical region is located around the navel (umbilicus) in the center of the abdomen. Pain in the umbilical region may be associated with conditions affecting the small intestine or structures around the navel, such as umbilical hernias. However, it does not specifically correspond to the description of pain below the xiphoid process in the middle section of the abdomen.

A. Report the client's abnormal lung sounds to the healthcare provider. B. Continue with the remainder of the client's physical assessment. C. Ask the client to cough and then auscultate at the site again. D. Measure the client's oxygen saturation with a pulse oximeter.

Correct Answer is B

Explanation

Choice A Reason:
Reporting the client's abnormal lung sounds to the healthcare provider is inappropriate. This option is not appropriate because vesicular breath sounds are actually normal lung sounds. They are soft, low-pitched sounds heard predominantly during inspiration in the peripheral lung fields. Reporting them as abnormal would be incorrect and could potentially lead to unnecessary concern or intervention.
Choice B Reason:
Continuing with the remainder of the client's physical assessment is appropriate. Vesicular breath sounds in the bases of both lungs posteriorly are normal findings. They indicate adequate ventilation and airflow in the lower lung fields. Therefore, there is no need for immediate intervention or further assessment specific to this finding. Continuing with the remainder of the physical assessment is appropriate to assess other aspects of the client's health.
Choice C Reason:
Asking the client to cough and then auscultate at the site again is inappropriate. Asking the client to cough and then auscultate again is not necessary in response to hearing vesicular breath sounds. Vesicular breath sounds are normal lung sounds and do not require further assessment or intervention. Coughing would not change the character of vesicular breath sounds.
Choice D Reason:
Measuring the client's oxygen saturation with a pulse oximeter is inappropriate. While measuring oxygen saturation with a pulse oximeter is an important assessment, it is not specifically indicated in response to hearing vesicular breath sounds. Vesicular breath sounds indicate normal ventilation and airflow in the lower lung fields, but they do not provide direct information about oxygenation status. Oxygen saturation should be assessed as part of a comprehensive respiratory assessment, but it does not need to be prioritized solely based on the finding of vesicular breath sounds.
$C:\Users\user\AppData\Local\Microsoft\Windows\INetCache\Content.MSO\43AD7F87.tmp$

View Question and Answer

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

During the admission assessment, a male client admitted with chest pain states he has no breathing problems and no trouble sleeping at night. To obtain further data regarding possible orthopnea, which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client reports experiencing stomach pain and it is localized in the middle section of the abdomen below the xiphoid process. The nurse should describe the pain as occurring in which region of the abdomen?

Correct Answer is A

Explanation

While auscultating a client's breath sounds, the nurse hears vesicular sounds in the bases of both lungs posteriorly. Which action should the nurse take in response to this finding?

Correct Answer is B

Explanation

An adult client exhibits an allergic reaction to an Insect bite. The nurse should observe the client's skin for which finding?

Patient Data Exhibits During the assessment, the nurse notes that the areas are filled with a fluid-like substance. Which of the following primary skin lesions contain fluid? Select all that apply.

A client is seen in the emergent care clinic for right wrist pain with a pattern of ecchymosis observed on the wrist. Which motion should the nurse instruct the client to perform to assess the wrist mobility?

When inspecting the client's skin, the nurse observes several areas of ecchymosis on the trunk and extremities. Which information in the client's history requires additional follow-up by the nurse?

To assess a client's pupillary reaction to accommodation, what action should the nurse take?

When assessing a client's range of motion, the nurse notes crepitation with movement of the left knee. Which information in the client's history is most likely related to this finding?

The nurse is performing an initial assessment of a client who has an expressionless facial affect, slurred speech, and red conjunctivae. Which question should the nurse ask first? "Have you..."

To assess a male client's muscle strength, the nurse first asks the client to extend his arms. Before asking the client to flex his arms, what should the nurse do?