Exhibits

Nurse analyzes the findings.
Which can the nurse do to mitigate artifacts when performing auscultation? Select all that apply.

Reach under a gown to listen and take care that no clothing rubs on the stethoscope

Keep the examination room warm, and warm the stethoscope

Wet the chest hair before auscultating

Ensure the room is as quiet as possible

Document the roaring and crackles

Answer and Explanation

Correct Answer : A,B,C,D

Rationale:
A. Reach under a gown to listen and take care that no clothing rubs on the stethoscope: Direct placement of the stethoscope on the skin prevents interference from clothing, which can cause extraneous "roaring" or scratching sounds. Ensuring no fabric rubs against the stethoscope helps obtain clearer, more reliable auscultation results.

B. Keep the examination room warm, and warm the stethoscope: A cold environment or cold stethoscope can trigger shivering in the client, leading to muscle movement noises during auscultation. Warming the room and stethoscope minimizes these artifacts and allows better evaluation of breath sounds without false interference.

C. Wet the chest hair before auscultating: Chest hair can create crackling or static sounds when it rubs against the stethoscope. Lightly wetting the hair reduces friction, ensuring that abnormal lung sounds like crackles are genuine findings and not artifacts caused by the hair movement.

D. Ensure the room is as quiet as possible: Background noise can make auscultation findings harder to hear and interpret. A quiet environment helps the nurse distinguish actual breath sounds from ambient noise, especially important when assessing for subtle abnormalities like crackles or decreased breath sounds.

E. Document the roaring and crackles: Documenting artifact sounds like roaring without first addressing the source could lead to incorrect clinical conclusions. Roaring caused by hair or clothing interference must be corrected before recording findings, so immediate documentation without artifact correction is not appropriate.

Nursing Test Bank

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Correct Answer is D

Explanation

Rationale:
A. "Can you recall the date the Twin Towers in New York were destroyed?": This question assesses memory, specifically long-term memory, rather than judgment. Remembering historical events evaluates cognitive recall ability but does not explore the client’s decision-making process.

B. "What is the difference between a hamster and a rabbit as a pet?": This question primarily assesses abstract thinking and categorization rather than judgment. It helps evaluate how the client organizes concepts but does not directly provide insight into practical decision-making or problem-solving skills.

C. "Should someone who lives in a glass house throw stones?": This proverb assesses abstract thinking and the ability to interpret symbolic meanings, rather than directly evaluating judgment. Interpretation of proverbs reflects cognitive function but not necessarily real-life decision-making capacity.

D. "Do you write checks if you know the bank account is overdrawn?": This question assesses practical judgment by exploring the client's ability to make appropriate decisions regarding real-world financial behavior. It directly addresses reasoning, consequences of actions, and impulse control, which are key elements of judgment evaluation.

A. Paresthesia reported. B. Circulation impaired. C. Inflammation present. D. Reports feeling "on fire."

Correct Answer is A

Explanation

Rationale:
A. Paresthesia reported: Paresthesia refers to abnormal sensations like burning, tingling, or numbness, typically due to nerve irritation or damage. Documenting it as "paresthesia reported" is clinically accurate, concise, and uses appropriate medical terminology to communicate the client’s symptom in the EMR.

B. Circulation impaired: Impaired circulation could cause symptoms like coldness, pallor, or numbness, but burning sensations more commonly suggest nerve involvement rather than vascular insufficiency. Labeling it as circulation impairment would not precisely reflect the client’s described symptom.

C. Inflammation present: Inflammation could cause redness, warmth, and swelling, but it is not the primary interpretation of a burning sensation unless there are visible signs of inflammatory response. Without objective evidence, assuming inflammation would be inaccurate documentation.

D. Reports feeling "on fire.": While documenting exact quotes can sometimes be valuable, using clear medical terminology in routine EMR documentation is preferred. "Paresthesia reported" professionally communicates the symptom while maintaining clinical clarity and avoiding subjective descriptions.

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Exhibits Nurse analyzes the findings. Which can the nurse do to mitigate artifacts when performing auscultation? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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Exhibits

Nurse analyzes the findings.
Which can the nurse do to mitigate artifacts when performing auscultation? Select all that apply.