The nurse continues the respiratory assessment of a client's chest excursion by placing both hands as seen in the picture. Which instruction should the nurse give the client?

Hold your breath.

Take a deep breath

Cough vigorously

Lean forward.

Answer and Explanation

The Correct Answer is B

A. Hold your breath: Holding the breath would prevent the nurse from observing chest movement during inhalation and exhalation, making it unsuitable for assessing chest excursion.

B. Chest excursion is assessed to evaluate the symmetry and depth of lung expansion. By instructing the client to take a deep breath, the nurse can observe the movement of both hands as the lungs expand. Symmetrical and adequate movement indicates normal lung function, while asymmetry may suggest conditions such as pneumothorax, pleural effusion, or atelectasis.

C. Cough vigorously: While coughing may be helpful in evaluating airway clearance or adventitious sounds, it is unrelated to chest excursion.

D. Lean forward: Leaning forward is not necessary for chest excursion assessment; this position is typically used for auscultating posterior lung sounds or relieving dyspnea in conditions like COPD.

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Correct Answer is C

Explanation

A. Babinski sign is related to abnormal reflexes, not coordination or balance.

B. Chvostek's sign is indicative of hypocalcemia, not alcohol intoxication.

C. Ataxia (uncoordinated movement) caused by intoxication is likely to be associated with a positive Romberg sign, which tests balance by asking the patient to stand with their feet together and eyes closed.

D. Battle sign refers to bruising behind the ears, often associated with head trauma, not intoxication.

A. Use a Doppler ultrasound to hear the heart beat B. Auscultate for one minute with the stethoscope's diaphragm. C. Listen to the heart sounds using the bell of a stethoscope. D. Obtain a pulse oximeter reading from two extremities.

Correct Answer is C

Explanation

A. Doppler ultrasound is used for assessing blood flow and is not necessary to verify heart sounds.

B. The diaphragm is better for hearing high-pitched sounds like normal heartbeats, murmurs, and lung sounds.

C. The bell of the stethoscope is best for auscultating low-pitched sounds, such as extra heart sounds like a S3 or S4, which are often related to heart failure or other cardiac conditions.

D. A pulse oximeter assesses oxygen saturation, not heart sounds.

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The nurse continues the respiratory assessment of a client's chest excursion by placing both hands as seen in the picture. Which instruction should the nurse give the client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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