What should the examiner do during auscultation of breath sounds?
Listen with the bell of the stethoscope.
Listen only to the posterior chest for adventitious sounds.
Instruct the patient to breathe in and hold their breath.
Compare the sounds on the left and right sides.
The Correct Answer is D
Choice A rationale
The bell of the stethoscope is designed to auscultate low-frequency sounds, such as certain heart murmurs or bowel sounds, due to its larger surface area and lower diaphragm tension. Breath sounds, however, are generally higher frequency and require the diaphragm for optimal clarity and discrimination of adventitious sounds, which are often subtle and require careful attention to pitch and quality.
Choice B rationale
Limiting auscultation to only the posterior chest misses significant lung fields, especially the anterior and lateral segments of the upper and middle lobes. Comprehensive respiratory assessment necessitates evaluating all accessible lung surfaces to detect localized abnormalities, ensuring no consolidation, atelectasis, or pleural effusions are overlooked, providing a complete diagnostic picture.
Choice C rationale
Instructing the patient to breathe in and hold their breath would prevent the continuous airflow necessary to generate breath sounds. Auscultation relies on the movement of air through the tracheobronchial tree. Holding the breath eliminates this vital acoustic phenomenon, rendering the assessment ineffective for evaluating air entry, presence of adventitious sounds, or symmetry.
Choice D rationale
Comparing sounds on the left and right sides allows for the identification of unilateral abnormalities, which are crucial for diagnosing localized pathologies. This systematic approach helps detect differences in breath intensity, the presence of unilateral adventitious sounds like wheezes or crackles, or diminished air entry, guiding further diagnostic investigation and treatment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Placing the patch in the same location repeatedly can lead to skin irritation, reduced absorption due to stratum corneum thickening, and localized adverse reactions. Rotation of application sites allows the skin to recover, maintains optimal drug absorption, and prevents cumulative dermal irritation.
Choice B rationale
Transdermal patches often contain significant amounts of medication, including controlled substances or potent drugs. Discarding them in the trash can poses risks of accidental exposure to others, environmental contamination, and diversion. Proper disposal protocols, such as flushing or returning to pharmacy, are crucial.
Choice C rationale
While transdermal patches are designed for systemic absorption, specific sites are recommended to optimize efficacy and minimize adverse effects. Areas with less hair, intact skin, and good circulation are preferred. Improper placement can lead to erratic absorption or local irritation, reducing therapeutic benefit.
Choice D rationale
The nurse should always wear gloves when handling transdermal patches to prevent direct skin contact with the medication. Many transdermal drugs can be absorbed through the nurse's skin, leading to unintended pharmacological effects or sensitization. Gloves provide a crucial barrier against dermal absorption.
Correct Answer is C
Explanation
Choice A rationale
Dullness upon percussion indicates increased tissue density, such as in consolidation (e.g., pneumonia), pleural effusion, or a tumor. This occurs because the sound waves are attenuated and dampened by the solid or fluid-filled structures, resulting in a short, high-pitched, thudding sound.
Choice B rationale
Tympany is a drum-like, high-pitched, loud sound typically heard over air-filled organs like the stomach or intestines. When percussing the lungs, tympany suggests a large pneumothorax or a distended abdomen impinging on the thoracic cavity, indicating abnormal air accumulation.
Choice C rationale
Resonance is the expected percussive sound over healthy, air-filled lung tissue. It is a low-pitched, clear, hollow sound produced by the vibration of air within the alveoli and bronchi. This sound indicates normal lung aeration and the absence of significant pathology.
Choice D rationale
Hyperresonance is a louder, lower-pitched sound than normal resonance and suggests an increased amount of air in the lung or pleural cavity, such as in emphysema or pneumothorax. This hyperinflation causes greater vibration and a more boomy quality to the sound.
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