The nurse is auscultating the lungs and hears vesicular sounds at the bases of the lungs. What should the nurse do next?

Obtain a pulse ox reading immediately

Notify the charge nurse or physician

Continue assessment as per usual

Start a nebulizer treatment

Answer and Explanation

The Correct Answer is C

A. Obtain a pulse ox reading immediately: Pulse oximetry is useful if there are abnormal signs, but hearing normal vesicular sounds at the bases and no distress does not make immediate SpO₂ measurement mandatory.

B. Notify the charge nurse or physician: Escalation is warranted for abnormal findings or patient distress; normal vesicular sounds at the bases do not require immediate notification.

C. Continue assessment as per usual: Vesicular breath sounds at the bases are expected normal findings in most adults - proceed with the rest of the assessment.

D. Start a nebulizer treatment: Nebulizer therapy is indicated for bronchospasm/wheezing or prescribed respiratory problems, not for normal vesicular sounds.

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Correct Answer is D

Explanation

A. Notify the surgeon immediately: Notifying the surgeon is appropriate for large or expanding drainage or signs of hemorrhage, but a small amount initially soaked into the dressing often warrants monitoring first.

B. Immediately change the surgical dressing: Routine dressing changes are performed per protocol; changing a dressing unnecessarily can increase infection risk and disrupt the initial postoperative seal unless the dressing is soaked through or contaminated.

C. There's no action is required: Doing nothing at all ignores the need to document and monitor drainage; some action to mark and observe is appropriate.

D. Circle the drainage on the dressing site and continue to monitor: Marking the drainage boundary and documenting the time allows tracking for increases - a standard immediate response to small, stable drainage.

A. Heart rate of 77 B. Urine output of 300 ml in 24-hour C. Temperature of 99.2 oral D. Pain rating 3 on 1-10 pain scale

Correct Answer is B

Explanation

A. Heart rate of 77: A heart rate of 77 bpm is within normal resting range for many adults and would not typically demand immediate intervention.

B. Urine output of 300 ml in 24-hour: 300 ml in 24 hours is markedly low (oliguria); inadequate urine output may indicate hypovolemia, renal impairment, or obstruction and requires immediate assessment and intervention.

C. Temperature of 99.2 oral: 99.2°F is a low-grade elevation and can be common after surgery; it is not usually an immediate emergency at 24 hours post-op.

D. Pain rating 3 on 1–10 pain scale: A pain score of 3 is mild/moderate and typically managed with routine analgesia and reassessment rather than immediate urgent action.

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The nurse is auscultating the lungs and hears vesicular sounds at the bases of the lungs. What should the nurse do next?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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