The nurse is observing the auscultation technique of another nurse.
The correct method to use when progressing from one auscultatory site on the thorax to another is:

Comparison.

Anterior to posterior.

Side-to-side.

Interspace by interspace.

Top to bottom.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Comparison is a broad principle of assessment, but "side-to-side" describes the specific methodical approach for auscultation. While comparison is the underlying goal, the physical act involves moving systematically between corresponding areas. Relying solely on a general comparison without a structured sequence can lead to omissions in assessment.

Choice B rationale

Progressing from anterior to posterior in one continuous sweep can lead to missed areas and a less systematic comparison of lung fields. Effective auscultation necessitates a structured approach that allows for direct comparison of symmetric areas, ensuring that subtle differences in breath sounds or adventitious sounds between sides are accurately identified.

Choice C rationale

The side-to-side method facilitates direct comparison of breath sounds between symmetrical lung fields, which is crucial for identifying unilateral abnormalities. This systematic approach ensures that each segment of the lung is assessed in relation to its contralateral counterpart, allowing for prompt detection of differences in air entry, quality, or presence of adventitious sounds.

Choice D rationale

While auscultating interspace by interspace is part of the technique, the overarching method for comparing sounds and ensuring comprehensive coverage is the side-to-side progression. Auscultating individual interspaces sequentially without direct contralateral comparison reduces the ability to identify subtle unilateral changes in lung sounds effectively.

Choice E rationale

A top-to-bottom approach, without consistent side-to-side comparison, can lead to inefficiencies and potential oversight of localized abnormalities. While auscultation generally proceeds superiorly to inferiorly, the critical aspect is the bilateral comparison at each corresponding level to detect subtle variations in breath sounds and identify pathology accurately.

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Correct Answer is D

Explanation

Choice A rationale

A drug allergy is an adverse immune-mediated reaction to a drug, involving antibodies or sensitized lymphocytes. Symptoms can range from rash and itching to anaphylaxis, occurring upon re-exposure. This client's reaction, wakefulness instead of sedation, does not align with typical allergic manifestations involving the immune system.

Choice B rationale

Drug tolerance is a diminished physiological response to a drug after repeated administration, requiring higher doses to achieve the same effect. This develops due to adaptive changes in drug receptors or metabolism. The client's experience of wakefulness, an opposite effect, is not indicative of tolerance to the drug's intended hypnotic action.

Choice C rationale

A toxic effect occurs when drug levels in the body exceed the therapeutic range, leading to harmful effects on organs or systems. This is often dose-dependent and can manifest as organ damage or severe side effects. While adverse, the described reaction of wakefulness is not typically classified as a toxic effect of Ambien.

Choice D rationale

An idiosyncratic reaction is an uncharacteristic or unpredictable response to a drug that is not an allergic reaction and does not involve known pharmacological properties. These reactions are often genetically determined and represent an individual's unique sensitivity. The paradoxical wakefulness from a sedative like Ambien is a classic example of an idiosyncratic drug response.

Correct Answer is ["5"]

Explanation

Step 1 is: Calculate the volume to administer. 75 mg ÷ (15 mg/mL) = 5 mL.

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The nurse is observing the auscultation technique of another nurse. The correct method to use when progressing from one auscultatory site on the thorax to another is:

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Naxlex Comprehensive Predictor Exams

An elderly client was given a dose of Ambien PO at bedtime for sleep and she was wide awake all night instead of going to sleep. This adverse reaction to a drug could be classified as a/an:

Correct Answer is D

Explanation

The physician has ordered Zantac elixir 75 mg PO bid for heartburn. The medication is supplied in 15 mg/mL. How many milliliters will the nurse administer? (Shade CUP #1 to correct dose & LABEL CORRECTLY TO RECEIVE CREDIT)

Correct Answer is ["5"]

Explanation

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The nurse is observing the auscultation technique of another nurse.
The correct method to use when progressing from one auscultatory site on the thorax to another is: