The nurse is examining a client for tactile fremitus. The nurse recognizes that when examining for tactile fremitus it is important to:
Have the client breathe quickly
Palpate the chest symmetrically
Ask the client to cough
Use the bell of the stethoscope
The Correct Answer is B
A. Have the client breathe quickly:
This choice is incorrect because having the client breathe quickly is not a technique for assessing tactile fremitus. Tactile fremitus is assessed by feeling vibrations on the chest wall while the patient speaks, not during normal breathing.
B. Palpate the chest symmetrically:
This choice is correct. To assess tactile fremitus, the nurse places the palms or ulnar aspects of both hands firmly against the patient's chest while the patient speaks a phrase. The nurse should palpate the chest symmetrically to detect vibrations equally on both sides, which can help identify abnormalities in the lungs.
C. Ask the client to cough:
This choice is incorrect. Asking the client to cough is not a technique for assessing tactile fremitus. Tactile fremitus is evaluated by feeling vibrations while the patient speaks, not while coughing.
D. Use the bell of the stethoscope:
This choice is incorrect. Tactile fremitus is assessed by palpation, not auscultation with a stethoscope. Using the bell of the stethoscope is a technique for listening to low-pitched sounds, not for assessing tactile fremitus.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Fifth intercostal space, left of the midclavicular line: This placement is used to auscultate the mitral valve, which is best heard at the apex of the heart. The mitral valve sounds are typically heard around the fifth intercostal space, midclavicular line.
B. Left lower sternal border: This placement is used to auscultate the tricuspid valve, which is best heard at the lower left sternal border.
C. Second left intercostal space: This is the correct placement for auscultating the pulmonic valve. The pulmonic valve sounds are best heard at the second left intercostal space, which is close to the upper left sternal border.
D. Second right intercostal space: This placement is used to auscultate the aortic valve, which is best heard at the second right intercostal space, close to the upper right sternal border.
Correct Answer is C
Explanation
In this sequence:
Vena cava brings deoxygenated blood from the body into the right atrium.
Blood flows from the right atrium to the right ventricle through the tricuspid valve.
The right ventricle pumps blood into the pulmonary artery to the lungs.
In the lungs, blood is oxygenated and returns to the heart via the pulmonary veins into the left atrium.
From the left atrium, blood moves to the left ventricle through the bicuspid (mitral) valve.
The left ventricle then pumps oxygenated blood into the body through the aorta.
This sequence represents the systemic and pulmonary circulation of the heart.
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