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 D

Explanation

A. WBC:The white blood cell count helps identify infection or inflammation but is not used to monitor the therapeutic effect of heparin. It does not provide information on anticoagulation status or bleeding risk.

B. D-dimer:D-dimer is useful for diagnosing or ruling out a PE initially but is not used to monitor treatment. Once anticoagulation has begun, D-dimer levels are not reliable indicators of therapeutic effectiveness.

C. PT/INR:PT/INR is used to monitor warfarin therapy, not heparin. Heparin affects the intrinsic pathway of the coagulation cascade, and PT/INR does not accurately reflect its anticoagulant effect.

D. aPTT:The activated partial thromboplastin time (aPTT) is the correct test to monitor heparin therapy. It measures the efficacy of the intrinsic clotting pathway and helps determine if the heparin dose is within the therapeutic range.

A. "It will reduce the frequency of your cough." B. "It should be used in the morning." C. "It should be taken before sleep." D. "It will eliminate your cough at night."

Correct Answer is C

Explanation

A. "It will reduce the frequency of your cough. Antitussives suppress the cough reflex and may reduce how often the patient coughs. However, this answer is vague and does not address the patient's concern and doesn't provide specific guidance on usage.

B. "It should be used in the morning." Antitussives are not recommended for use in the morning unless the cough is disruptive to daytime function. Taking them in the morning could lead to daytime drowsiness, if the medication contains sedating agents like codeine.

C. "It should be taken before sleep." This is the best response because antitussives are often most beneficial at night when coughing can disrupt sleep. Administering them before bed helps reduce nocturnal coughing and supports rest, which is essential for recovery.

D. "It will eliminate your cough at night." While antitussives may greatly reduce coughing, they do not guarantee total elimination of the cough. This statement creates unrealistic expectations and may mislead the patient regarding the effectiveness of the medication.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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