The nurse is performing the technique shown. What is the nurse assessing?

Tactile fremitus

Chest expansion

Breath sounds

Tissue consolidation

Answer and Explanation

The Correct Answer is B

A. Tactile fremitus: This involves palpating vibrations on the chest wall as the patient speaks, not assessing chest expansion.

B. Chest expansion: This technique assesses the symmetrical movement of the chest during inhalation and exhalation, which is the correct assessment for this context.

C. Breath sounds: Breath sounds are assessed through auscultation rather than palpation.

D. Tissue consolidation: This involves detecting areas of increased density in lung tissue, often assessed through percussion or auscultation, not through the technique shown for chest expansion.

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Correct Answer is C

Explanation

A. II: A grade II murmur is generally faint but still audible with the stethoscope in place.

B. III: A grade III murmur is moderately loud and can be heard with the stethoscope without applying extra pressure.

C. I: A grade I murmur is very faint and might be heard only with careful listening and with the stethoscope placed carefully.

D. X: There is no grade X murmur in the standard grading scale for heart murmurs.

A. Reduce all environmental noise. B. Percuss the region before auscultating. C. Palpate the region before auscultating. D. Assist the client to a sitting position.

Correct Answer is A

Explanation

A. Reduce all environmental noise: Minimizing environmental noise ensures that bowel sounds can be clearly heard during auscultation.

B. Percuss the region before auscultating: Percussion is not necessary before auscultation for detecting bowel sounds; auscultation should be done first.

C. Palpate the region before auscultating: Palpation can alter bowel sounds or cause false findings, so it is best to auscultate first.

D. Assist the client to a sitting position: The client’s position is less critical than reducing background noise; the client can be in various positions as long as the area is accessible.

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The nurse is performing the technique shown. What is the nurse assessing?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During chest auscultation, the nurse hears a quiet murmur immediately upon placing the stethoscope on the client's chest. The nurse interprets this as which grade?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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