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:
Getting a longer cord for the telephone may reduce the risk of tripping over a short cord but could potentially introduce new tripping hazards if not managed properly. It's important to keep cords secured and out of walkways to prevent falls.

Choice b reason:
Placing a throw rug over electrical cords is not advisable as it can create a tripping hazard. Rugs should be secured with non-slip backing and kept away from high-traffic areas to prevent falls.

Choice c reason:
Using handrails in the bathroom is a recommended safety measure to prevent falls. Bathrooms can be slippery, and handrails provide support and stability for residents when moving around in this area.

Choice d reason:
Using chairs without armrests is not a recommended practice for fall prevention. Chairs with armrests can aid residents in safely sitting down and standing up, providing support and reducing the risk of falls.

A. Penlight B. Gloves C. Gauze pad D. Tongue blade

Correct Answer is C

Explanation

Choice a reason:
A penlight is used to provide illumination during an examination, not to move the tongue. It helps the nurse to visualize the mouth floor and other areas by casting light, but it does not have the physical structure to manipulate the tongue.

Choice b reason:
Gloves are worn by healthcare professionals to maintain hygiene and protect both the patient and the nurse from the transmission of infectious agents. They are not used to move the tongue to one side during an examination.

Choice c reason:
A gauze pad is the correct tool to use when the nurse needs to move the tongue to one side during an examination of the mouth floor. The nurse can wrap the gauze pad around the tongue for a better grip, which allows for safe and effective retraction of the tongue without causing discomfort to the patient.

Choice d reason:
A tongue blade, also known as a tongue depressor, is typically used to depress the tongue to examine the back of the throat, not to move the tongue to one side. It is used to hold the tongue down so that the nurse can inspect the oropharynx and other structures.

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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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