The nurse notes an enlarged, visible lymph node on the client's neck. Which action should the nurse take next?

Auscultate the lymph node for the presence of a bruit.

Ask the client about any localized tenderness at the site.

Cover the inflamed area and notify the healthcare provider.

Record this normal finding in the assessment record.

Answer and Explanation

The Correct Answer is B

A. Auscultate the lymph node for the presence of a bruit.

Auscultating for a bruit over a lymph node may not be the most immediate or relevant action in this situation. While it could provide additional information about blood flow, it may not necessarily explain the cause of the enlarged lymph node.

B. Ask the client about any localized tenderness at the site.

This is an appropriate action. Localized tenderness at the site of an enlarged lymph node could indicate inflammation or infection. Gathering information about tenderness can help in understanding the possible cause of the lymphadenopathy.

C. Cover the inflamed area and notify the healthcare provider.

This is a reasonable action. Covering the inflamed area can help protect it from further irritation or infection. Notifying the healthcare provider is important because they can assess the lymph node, gather additional history, and determine if further evaluation or treatment is necessary.

D. Record this normal finding in the assessment record.

This option is incorrect. An enlarged, visible lymph node is not considered a normal finding. It could indicate underlying infection, inflammation, or another health issue. Recording it as a normal finding could lead to overlooking potential health concerns.

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Correct Answer is C

Explanation

A. Use a stethoscope to listen to and compare breath sounds anteriorly and posteriorly. This action is used to assess breath sounds, not tactile fremitus.

B. Looking at the client from the side, observe the size and shape of the chest wall. This action helps in assessing the general appearance and shape of the chest but does not assess tactile fremitus.

C. Place the palm of the hand on the chest wall to feel vibrations while the client speaks. This is the correct technique to assess tactile fremitus. Increased fremitus can indicate consolidation, as in pneumonia.

D. Use the fingertips to compress tissue over the lungs for evidence of a crackling sensation. This action is associated with palpating for crepitus, not assessing tactile fremitus.

A. A bubbling sound heard during inspiration and expiration in the central airways. B. A crowing noise heard during inspiration over the trachea. C. Popping, nonmusical sounds heard in the lung bases, usually during inspiration. D. Superficial squeaking or grating sounds heard during inspiration and expiration.

Correct Answer is C

Explanation

A. A bubbling sound heard during inspiration and expiration in the central airways: This description is accurate. Crackles (also called rales) are often heard in conditions like pulmonary edema or pneumonia.

B. A crowing noise heard during inspiration over the trachea: This description refers to stridor, not crackles. Stridor occurs due to upper airway obstruction.

C. Popping, non-musical sounds heard in the lung bases, usually during inspiration: This description is accurate for crackles. They occur due to fluid or secretions in the alveoli.

D. Superficial squeaking or grating sounds heard during inspiration and expiration: This description refers to wheezes, not crackles. Wheezes are associated with narrowed airways.

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The nurse notes an enlarged, visible lymph node on the client's neck. Which action should the nurse take next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

In assessing tactile fremitus in the client with suspected pneumonia, the nurse should perform which action?

Correct Answer is C

Explanation

The nurse hears crackles when auscultating a client's lung sounds. Which is an accurate description of the sound of crackles?

Correct Answer is C

Explanation

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