The nurse is preparing to auscultate for heart sounds on a client. Which of the following technique should be used by the nurse?

Listening for all possible sounds at a time at each specified area.

Listening to the sounds at the aortic, tricuspid, pulmonic, and mitral areas.

Listening to the sounds only at the site where the apical pulse is felt to be the strongest.

Listening by inching the stethoscope in a rough Z pattern, from the base of the heart across and down, then over to the apex.

Answer and Explanation

The Correct Answer is D

A. Listening for all possible sounds at a time at each specified area: This approach does not allow for specific localization of different heart sounds and murmurs, making it difficult to accurately assess the heart's condition.

B. Listening to the sounds at the aortic, tricuspid, pulmonic, and mitral areas: This option is close but lacks the systematic approach of method D. Listening at specific anatomical locations (aortic, tricuspid, pulmonic, mitral) is important, but the Z pattern allows for thorough coverage and precise localization of any abnormal sounds.

C. Listening to the sounds only at the site where the apical pulse is felt to be the strongest: This method does not cover all the important auscultation sites on the heart and may miss significant findings.

D. Listening by inching the stethoscope in a rough Z pattern, from the base of the heart across and down, then over to the apex: This technique involves a systematic approach where the nurse listens at specific locations in a structured manner, ensuring comprehensive coverage of the heart sounds and murmurs.

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Correct Answer is D

Explanation

A. Clear and equal breath sounds bilaterally

Explanation: Clear and equal breath sounds bilaterally indicate normal lung sounds, suggesting proper air exchange in both lungs. This is a normal finding and does not require immediate reporting.

B. Oxygen saturation of 98% on room air

Explanation: An oxygen saturation level of 98% on room air indicates adequate oxygenation of the blood. This is a normal and healthy oxygen saturation level and does not require immediate reporting.

C. Cough producing clear, thin sputum

Explanation: A cough producing clear, thin sputum is indicative of a non-infected or non-inflammatory condition in the respiratory system. Clear and thin sputum is often normal, especially in the absence of other symptoms. It does not require immediate reporting unless the client has other concerning symptoms.

D. Visible use of accessory muscles during inhalation

Explanation: Visible use of accessory muscles, such as neck or intercostal muscles, during inhalation suggests that the client is working hard to breathe. This could indicate respiratory distress, potentially due to conditions like asthma, COPD (Chronic Obstructive Pulmonary Disease), or other severe lung problems. It's a concerning sign and should be reported to the healthcare practitioner promptly for further evaluation and intervention.

A. Have the client breathe quickly B. Palpate the chest symmetrically C. Ask the client to cough D. Use the bell of the stethoscope

Correct Answer is B

Explanation

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.

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