The nurse is preparing to percuss a client's anterior chest area. Which approach will the nurse use for this assessment?

Begin above the right clavicle and percuss each section, comparing the right chest with the left chest.

Begin at the sternal notch and percuss all areas on the left chest, then all areas on the right chest.

Begin at the sternal notch and percuss all areas on the right chest, then all areas on the left chest.

Begin above the left clavicle and percuss all areas on the left chest, then reverse the process and assess the right chest, moving upward from the liver.

Answer and Explanation

The Correct Answer is A

Choice A Reason:
This approach is recommended as it allows for a systematic comparison between the two sides of the chest. Percussion should start at the apices of the lungs, which are located just above the clavicles, and proceed downwards. This method ensures that any differences in percussion note, which could indicate underlying pathology, are identified by direct comparison.

Choice B Reason:
While this approach also involves a systematic assessment, it does not allow for immediate comparison between the two sides of the chest. It is important to compare corresponding areas on each side as you go to detect any asymmetry or changes in resonance.

Choice C Reason:
This method, similar to choice B, does not facilitate immediate side-to-side comparison during the assessment. Immediate comparison is crucial for identifying subtle differences that may indicate conditions such as pleural effusion or pneumothorax.

Choice D Reason:
Starting the percussion above the left clavicle and moving to the right chest after completing the left side does not allow for direct comparison of symmetrical chest areas. Additionally, assessing the right chest moving upward from the liver is not a standard practice, as the liver dullness can interfere with the percussion of the lower right lung fields.

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Correct Answer is C

Explanation

Choice a reason:
Rhonchi are coarse, rattling respiratory sounds somewhat like snoring, usually caused by obstruction or secretion in the larger airways. They are not considered normal breath sounds and are typically heard in conditions such as chronic bronchitis.

Choice b reason:
Crackles are the sounds you will hear in a lung field that has fluid in the small airways. These sounds are commonly heard in patients with pneumonia, heart failure, and restrictive pulmonary diseases. They are not normal breath sounds.

Choice c reason:
Bronchovesicular sounds are normal breath sounds heard over the main bronchus area and over the upper right posterior lung field. They have a medium pitch and intensity and are heard on both inspiration and expiration. In a healthy individual, these sounds are expected to be heard in the 1st and 2nd intercostal spaces near the sternal body.

Choice d reason:
Tracheal breath sounds are harsh, high-pitched sounds heard when auscultating over the trachea in the neck. They are not normally heard over the intercostal spaces of the chest wall.

A. Peripheral vision. B. External eye structures. C. Distant vision. D. Near vision.

Correct Answer is C

Explanation

Choice A reason:
Peripheral vision is the ability to see objects and movement outside of the direct line of vision. This type of vision is assessed using different methods, such as confrontation visual field testing, where the examiner moves objects into the patient's side vision from different angles. Standing 20 feet away from a chart would not be the appropriate method to assess peripheral vision.
Choice B reason:
The assessment of external eye structures involves examining the physical appearance and condition of the eyelids, sclera, conjunctiva, and surrounding areas. This is typically done at a close range and does not require the patient to stand at a distance from a chart. The nurse would inspect these structures directly, often with the aid of a penlight for better visibility.

Choice C reason:
Distant vision is the ability to see objects far away, and it is what the nurse is preparing to assess when the client is asked to stand 20 feet from a chart. This distance is standard for the Snellen eye chart, which is used to measure visual acuity. The chart has rows of letters that decrease in size, and the patient is asked to read the smallest line of letters they can see clearly. The Snellen chart is the most common method used by eye doctors to measure visual acuity.
Choice D reason:
Near vision is the ability to see objects that are close to the eyes clearly. It is assessed using different charts, such as the Jaeger eye chart, which contains blocks of text in various type sizes. The patient is asked to read the text at a close range, typically around 14 inches, not 20 feet. Therefore, standing 20 feet away from a chart would not be the method to assess near vision.

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The nurse is preparing to percuss a client's anterior chest area. Which approach will the nurse use for this assessment?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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