When auscultating a client's lungs, where should the practical nurse (PN) place the stethoscope first?

Clavicle.

Sternum.

Lung apex.

Aortic site.

Answer and Explanation

The Correct Answer is C

Rationale:

A. Clavicle: The clavicle is a bony structure that does not overlie lung tissue, so placing the stethoscope here would not allow auscultation of lung sounds. It is important to position the stethoscope over areas where airflow can be heard clearly.

B. Sternum: The sternum is also a central bony structure and does not provide access to lung fields. Auscultation over the sternum would mainly transmit cardiac sounds, not lung sounds, limiting the assessment of pulmonary function.

C. Lung apex: The apex of the lung, located just above the clavicles, is the correct starting point for auscultation. Beginning at the apex allows the PN to assess airflow in the upper lung fields first and then move systematically downward and posteriorly to compare lung sounds bilaterally, ensuring a thorough respiratory assessment.

D. Aortic site: The aortic site refers to a cardiac auscultation landmark, not a pulmonary field. Placing the stethoscope here is used to assess heart sounds, specifically the aortic valve area, and would not provide reliable information about lung function.

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Correct Answer is A

Explanation

Rationale:

A. Uneven chest movements: Uneven or asymmetric chest expansion after a thoracentesis may indicate complications such as a pneumothorax or pleural effusion. This finding is clinically significant because it reflects impaired lung expansion and potential respiratory compromise, requiring immediate notification of the healthcare provider.

B. Gag reflex that has not returned: While assessing the gag reflex is important for airway protection, it is more relevant after procedures involving sedation, anesthesia, or airway instrumentation. Thoracentesis typically does not affect cranial nerve function or the gag reflex, making this finding less pertinent in this context.

C. Decrease in the baseline of the heart rate: A mild variation in heart rate may occur due to pain, anxiety, or activity, but a decrease alone without other symptoms such as hypotension or oxygen desaturation is not the most urgent indicator of post-thoracentesis complications.

D. Nasal congestion: Nasal congestion is unrelated to thoracentesis and does not reflect complications from the procedure. While it may require symptomatic management, it is not a priority finding for post-procedure monitoring.

A. Hemoglobin 8.9 grams/dL (89 g/L). B. Potassium 3.4 mEq/L (3.4 mmol/L). C. Sodium 130 mEq/L (130 mmol/L). D. Blood urea nitrogen 20 mg/dL (7.14 mmol/L).

Correct Answer is A

Explanation

Rationale:

A. Hemoglobin 8.9 grams/dL (89 g/L): This value is significantly below the normal range of 12–16 g/dL, indicating anemia, likely from perioperative blood loss. Low hemoglobin can compromise oxygen delivery to tissues, increase risk for hypoxia, and cause tachycardia, hypotension, or dizziness, which are critical safety concerns for a postoperative client.

B. Potassium 3.4 mEq/L (3.4 mmol/L): This is slightly below the normal range of 3.5–5.0 mEq/L, indicating mild hypokalemia. While important for cardiac and neuromuscular function, the degree of deviation is less immediately life-threatening than severe anemia in the early postoperative period.

C. Sodium 130 mEq/L (130 mmol/L): Hyponatremia below the normal range of 136–145 mEq/L can lead to neurological changes such as confusion or seizures. However, in the context of immediate postoperative safety, the oxygen-carrying deficit from low hemoglobin has a more direct impact on vital organ perfusion.

D. Blood urea nitrogen 20 mg/dL (7.14 mmol/L): This value is at the upper limit of the normal range (10–20 mg/dL) and may reflect mild renal stress or dehydration but does not pose an immediate safety risk compared with severe anemia post-surgery.

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When auscultating a client's lungs, where should the practical nurse (PN) place the stethoscope first?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

Correct Answer is A

Explanation

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When auscultating a client's lungs, where should the practical nurse (PN) place the stethoscope first?