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

A.

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

B.

Use the bell of the stethoscope held lightly against the chest

C.

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

D.

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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Related Questions

Correct Answer is ["0.5"]

Explanation

Calculation:

Desired dose = 5,000 units.

Available concentration = 10,000 units/mL.

  • Calculate the volume to administer.

Volume (mL) = Desired dose (units) / Available concentration (units/mL)

= 5,000 units / 10,000 units/mL

= 0.5 mL..

Correct Answer is D

Explanation

A. Blood pressure of 138/84 mmHg:This is within the acceptable range for a 68-year-old adult, especially with a history of hypertension. It does not indicate an acute threat or require immediate intervention in the context of pneumonia.

B. WBC count of 15,000/mm³:An elevated WBC count is expected in response to infection, such as pneumonia. While it confirms an inflammatory process, it is not the most urgent issue requiring immediate nursing action.

C. Blood glucose of 198 mg/dL:This mild hyperglycemia is not uncommon in infections and stress responses, particularly in patients with diabetes. It should be monitored, but it is not an immediate danger to the patient.

D. Oxygen saturation 89%:This low oxygen saturation indicates hypoxemia and impaired gas exchange, which is critical in a patient with pneumonia. Immediate oxygen therapy is necessary to prevent tissue hypoxia and respiratory failure.

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