The nurse is observing the lung auscultation technique of a student nurse. What is the correct method to use when progressing from one auscultatory site to another?
Posterior to anterior comparison
Side-to-side comparison
Interspace-by-interspace comparison
Proximal to distal comparison
Top-to-Bottom comparison
The Correct Answer is B
A. While posterior to anterior comparisons are used, they do not encompass the entire technique for auscultation.
B. Side-to-side comparison is the correct method as it allows for immediate assessment of differences between lung fields and helps to identify abnormal sounds effectively.
C. Interspace-by-interspace comparison is not a commonly recognized term for this method and can lead to confusion in technique.
D. Proximal to distal comparison is not specific to lung auscultation and does not effectively apply to lung assessment.
E. Top-to-bottom comparison may miss abnormalities in a specific region of the lungs; side-to-side is preferred.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Auscultate for any cardiac murmurs is correct, as a thrill often indicates turbulent blood flow, which may correlate with murmurs that can be heard upon auscultation.
B. Comparing apical and radial pulse rates is useful in assessing pulse deficits but does not directly address the cause of the thrill.
C. Palpating the quality of the peripheral pulses does not provide specific information about the thrill's origin.
D. Finding the point of maximal impulse is a useful cardiac assessment but does not directly explain the cause of the thrill.
E. Checking capillary refill time assesses peripheral perfusion but does not relate to the thrill's cause.
Correct Answer is ["A","B","E"]
Explanation
A. An S3 is often associated with a stiff or poorly compliant ventricle.
B. An S3 heart sound can be an indication of congestive heart failure in adults, as it reflects increased fluid volume and pressure in the ventricles.
C. S3 is heard just after S2, not S1.
D. The S3 heart sound is not always pathologic. It is often benign in children, adolescents, and young adults, where it may occur due to a rapid filling phase of the ventricles.
E. In adolescents and younger individuals, an S3 heart sound is usually considered a normal finding.
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