The nurse is performing a physical assessment on the respiratory system. Although the client is currently confined to bed, they have the strength and ability to move and reposition themselves. The nurse instructs the client to assume which position for the assessment?

Choice A reason: Listening to at least one full respiration in each location is a proper technique for respiratory assessment. It ensures that the nurse can accurately assess the breath sounds and identify any abnormalities. This method allows for a thorough evaluation of the respiratory system, ensuring that no areas are missed.

Choice B reason: Instructing the client to breathe in and out rapidly while listening to breath sounds is incorrect. Rapid breathing can lead to hyperventilation and may not provide an accurate representation of the client’s normal breath sounds. The proper technique is to instruct the client to take slow, deep breaths through their mouth, which allows for a more accurate assessment of the breath sounds and any potential abnormalities.

Choice C reason: Listening to breath sounds through the hospital gown or clothing is incorrect. Clothing can interfere with the sounds and may lead to inaccurate assessments. The proper technique is to place the stethoscope directly on the client’s skin to ensure that the breath sounds are heard clearly and accurately.

Choice D reason: Instructing the client to take slow deep breaths through his or her nose is partially correct but not ideal. While slow deep breaths are appropriate, they should be taken through the mouth to ensure that the breath sounds are more pronounced and easier to assess. Breathing through the nose can sometimes muffle the sounds and make it harder to detect abnormalities.

Choice E reason: Listening as the client inhales and then moving to the next site during exhalation is incorrect. The nurse should listen to both the inhalation and exhalation phases of respiration at each site. This ensures a complete assessment of the breath sounds and helps in identifying any abnormalities that may be present during either phase of respiration.

Choice A reason:

Sitting upright is the best position for a respiratory assessment. This position allows for optimal lung expansion and makes it easier to auscultate breath sounds accurately. It also helps in observing the client’s breathing pattern and effort.

Choice B reason:

Semi-Fowler’s position, where the head of the bed is elevated to 30-45 degrees, is often used for clients with respiratory issues to promote lung expansion and reduce the risk of aspiration. However, it is not as effective as the sitting upright position for a thorough respiratory assessment.

Choice C reason:

The supine position, where the client lies flat on their back, is not ideal for a respiratory assessment. This position can limit lung expansion and make it more difficult to hear breath sounds clearly.

Choice D reason:

The side-lying position is also not suitable for a respiratory assessment. This position can cause uneven lung expansion and make it challenging to assess both lungs accurately.