The nurse is auscultating the chest in an adult client. Which technique is correct?

Have the client lean over an over-the-bed table.

Use the bell of the stethoscope held lightly against the chest

Use the diaphragm of the stethoscope held firmly against the chest.

Instruct the client to take deep, rapid breaths through their nose.

Answer and Explanation

The Correct Answer is C

A. Have the client lean over an over-the-bed table: This position is sometimes used during posterior thoracic examination or for percussing lung fields, but it is not standard for routine chest auscultation. Most chest sounds can be assessed with the client sitting upright or lying down.

B. Use the bell of the stethoscope held lightly against the chest: The bell is best for detecting low-pitched sounds like some heart murmurs, not respiratory sounds. Lung sounds are higher-pitched and require use of the diaphragm for accurate auscultation.

C. Use the diaphragm of the stethoscope held firmly against the chest: This is the correct technique for auscultating lung sounds, which are typically high-pitched. Holding the diaphragm firmly ensures clear transmission of breath sounds such as crackles, wheezes, or rhonchi.

D. Instruct the client to take deep, rapid breaths through their nose: Deep breathing is appropriate during auscultation, but it should be done through the mouth. Breathing through the nose may reduce air entry and obscure abnormal sounds, making it harder to detect lung pathology.

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Correct Answer is B

Explanation

A. Determining the last time the patient was suctioned:The timing of previous suctioning is not a reliable indicator of current need. Suctioning is a clinical decision based on assessment, not a fixed schedule or time interval.

B. Auscultating the breath sounds:Listening to lung sounds helps detect the presence of secretions, such as crackles or rhonchi, indicating airway obstruction. This is the most direct and effective method to assess the need for suctioning in a tracheostomized patient.

C. Monitoring the rate of respirations:An increased respiratory rate can suggest respiratory distress but is non-specific and may result from various causes, including anxiety, fever, or pain. It does not definitively indicate the presence of secretions.

D. Examining the character of the sputum:Sputum characteristics provide information about infection or hydration status, but unless secretions are visibly present or obstructing the airway, they don’t confirm the immediate need for suctioning.

A. drive to breathe may be dependent on low levels of oxygen in the blood B. respiratory rate may be increased a great part of the time C. lung stretch receptors may fail to monitor the patterns of breathing D. intercostal muscles contract during inspiration, but fail to relax during expiration

Correct Answer is A

Explanation

A. Drive to breathe may be dependent on low levels of oxygen in the blood: Clients with emphysema may have chronically elevated CO₂ levels, which can blunt their central chemoreceptor response. As a result, their respiratory drive may rely more on peripheral chemoreceptors sensing low oxygen levels.

B. Respiratory rate may be increased a great part of the time: While some clients with emphysema may exhibit tachypnea during exertion or exacerbations, this is not a consistent or defining characteristic across all situations.

C. Lung stretch receptors may fail to monitor the patterns of breathing: Lung stretch receptors play a role in the Hering-Breuer reflex, but there is no evidence that they fail to function in emphysema. The issue in emphysema is gas trapping and reduced surface area for gas exchange, not receptor failure.

D. Intercostal muscles contract during inspiration, but fail to relax during expiration: The intercostal muscles assist with ventilation, particularly during increased respiratory effort. However, their relaxation in expiration is typically passive and not impaired in emphysema.

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The nurse is auscultating the chest in an adult client. Which technique is correct?

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