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.

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 C

Explanation

A. Palpating in the wrong abdominal quadrant: The gallbladder is located in the right upper quadrant, so palpating in the wrong area would not be the cause here.

B. Deeper palpation technique is needed: Although obesity can make palpation more difficult, it is more likely that the inability to locate the gallbladder is due to the fat tissue rather than the need for a different technique.

C. In most healthy individuals, the gallbladder is not palpable during a physical examination unless it is inflamed, distended, or diseased (e.g., cholecystitis or cholelithiasis). Therefore, not being able to palpate the gallbladder is a normal finding and usually indicates there is no underlying pathology.

D. While obesity may sometimes obscure palpation, in this context, the primary reason the gallbladder is not felt is because it is normal, not necessarily because of body habitus. The gallbladder is typically not palpable in anyone, regardless of weight.

A. Small joints of the hand B. Joint swelling C. Morning stiffness quickly resolve D. Fatigue and fever E. Symmetrical involvement F. Pain increases with motion G. Heberden nodes

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"},"G":{"answers":"B"}}

Explanation

Small joints of the hand: Rheumatoid arthritis (RA) typically affects the small joints of the hands, such as the metacarpophalangeal and proximal interphalangeal joints.

Joint swelling: Inflammatory joint swelling is a hallmark of RA.

Morning stiffness quickly resolves: This is not associated with RA. In RA, morning stiffness often lasts for more than 30 minutes, distinguishing it from conditions like osteoarthritis where stiffness resolves quickly.

Fatigue and fever: Systemic symptoms such as fatigue and low-grade fever can accompany RA due to the inflammatory nature of the disease.

Symmetrical involvement: RA is characterized by symmetrical joint involvement, unlike osteoarthritis or other conditions that may involve joints asymmetrically.

Pain increases with motion: Joint pain that worsens with movement is common in RA due to inflammation.

Heberden nodes: These bony enlargements of the distal interphalangeal joints are a feature of osteoarthritis, not RA.

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

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

While assessing a client who is obese, the nurse is unable to locate the gallbladder when palpating below the liver margin at the lateral border of the rectus abdominal muscle. Which is the most likely explanation for failure to locate the gallbladder by palpation?

Correct Answer is C

Explanation

Patient Data Click to indicate which findings are indicative of rheumatoid arthritis or are not applicable to that disease. Each row must have only one response option selected.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"},"G":{"answers":"B"}}

Explanation

An older adult client is being evaluated for admission to an assisted living facility. During the health assessment, the nurse implements which technique to determine the client's ability to reside in this environment?

The nurse observes that the lower legs of a client with diabetes mellitus are shiny, and with no hair growth. To obtain additional data to support these findings, which assessment should the nurse perform?

While conducting a physical assessment, the nurse shines a pen light into a client's right eye and moves the light source to check the client's left eye. Which finding indicates the need for further evaluation?

A nurse performs a Tinetti assessment on an older adult client and calculates a balance score of 12 and a gait score of 8. Which do these results indicate?

When performing a skin and nail exam on an older adult female client, the nurse notes that she has longitudinal ridges on her fingernails. What does this finding indicate?

Which question by the nurse is likely to elicit the most information regarding a client's use of medications to treat a chronic cough?

The school nurse is interviewing a 13-year-old girl who wants to go home from school because of "back pain." Which question should the nurse ask the adolescent first?

The nurse is assessing a client who has a history of kidney stones and returns to the clinic with flank pain. Which intervention should the nurse implement first?