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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Observing the pupillary response to a penlight assesses the direct and consensual light reflex, not visual acuity.
B. Snellen chart testing is the standard method for assessing visual acuity and can help support the claim of legal blindness.
C. Observing the optic disc through an ophthalmoscope evaluates the internal eye structures but does not directly assess visual acuity.
D. Observing the cardinal fields of vision tests eye movements but does not evaluate overall visual acuity.
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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