The nurse completes auscultation of the thoracic region on an adolescent client. Which finding is considered normal for this client?

Adventitious sounds.

No adventitious sounds.

Rhonchi.

Absent sounds.

Answer and Explanation

The Correct Answer is B

A. Adventitious lung sounds include wheezes, crackles (rales), stridor, and pleural rubs. These sounds indicate abnormalities in the respiratory system, such as asthma, pneumonia, bronchitis, pulmonary edema, or pleural inflammation. In a healthy adolescent, these sounds are not expected. Detecting adventitious sounds would prompt further assessment, including history, oxygenation status, and potentially diagnostic testing like a chest X-ray or pulmonary function tests.

B. This is the expected normal finding. Normal breath sounds are primarily vesicular over most of the lung fields, characterized by soft, low-pitched sounds during inspiration that are slightly shorter and quieter during expiration. Clear lung sounds with no added noises indicate unobstructed airways, normal alveolar ventilation, and proper gas exchange. This finding is consistent with healthy respiratory function in an adolescent.

C. Rhonchi are coarse, low-pitched rattling sounds, often caused by airway secretions in the larger bronchi. They are commonly heard in conditions such as bronchitis, chronic obstructive pulmonary disease (COPD), or pneumonia. Rhonchi are abnormal findings and may clear somewhat with coughing, but their presence signals airway obstruction or excess secretions.

D. Absence of breath sounds in any area of the lungs is a serious abnormality. It may indicate lung collapse (atelectasis), pneumothorax, severe obstruction, or pleural effusion, all of which can compromise oxygenation and require immediate intervention. This is never a normal finding in an adolescent or any healthy individual.

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Correct Answer is A

Explanation

A. This is the most appropriate action. The client is likely experiencing postherpetic neuralgia, which is a common complication after herpes zoster. Pain may persist even after the viral lesions have resolved. Assessing current analgesic use allows the nurse to determine whether pain management is adequate and whether additional or alternative interventions are needed. This ensures timely relief while avoiding over- or under-medication.

B. While it is true that the viral infection has resolved, reassurance alone is insufficient. Postherpetic neuralgia can persist for weeks to months, and clients require active pain management and follow-up, not just verbal reassurance.

C. Education about antiviral therapy is important during active infection, but this client has already completed treatment. Emphasizing completion at this stage is unnecessary and does not address the current symptom of pain.

D. Since the viral infection has been successfully treated, resuming antivirals is not indicated. Antiviral therapy does not relieve postherpetic neuralgia once the infection has resolved.

A. Hydromorphone. B. Ondansetron. C. Naloxone. D. Enoxaparin.

Correct Answer is A

Explanation

A. Hydromorphone is a potent opioid analgesic. It has a rapid onset of action, typically within 10–30 minutes when given intravenously, and slightly longer for subcutaneous or intramuscular administration. Nurses must monitor for both therapeutic effects, such as pain relief, and adverse reactions, including respiratory depression, sedation, hypotension, and nausea, within the first 30 minutes after administration. This close observation period is critical because opioid-related complications can occur quickly.

B. Ondansetron is an antiemetic used to prevent or treat nausea and vomiting. While it is important to monitor the client for effectiveness and possible side effects (e.g., headache, constipation, or QT prolongation), these typically do not require intensive monitoring immediately after administration.

C. Naloxone is an opioid antagonist used to reverse opioid overdose. Its effect occurs within minutes, often faster than 30 minutes, and monitoring focuses on respiratory status and reversal of opioid effects. While rapid observation is essential, its use is generally for emergency situations rather than routine post-administration monitoring of a newly prescribed medication.

D. Enoxaparin is a low-molecular-weight heparin used for anticoagulation. Monitoring focuses on signs of bleeding or thrombocytopenia, and therapeutic effect is generally assessed over days, not minutes after administration. Immediate post-administration monitoring within 30 minutes is usually not required for routine doses.

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The nurse completes auscultation of the thoracic region on an adolescent client. Which finding is considered normal for this client?

Nursing Test Bank

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Correct Answer is A

Explanation

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