When listening to a patient's breath sounds, the nurse is unsure of a sound that is heard. The nurse's next action should be to:

Assess again in 20 minutes to note whether the sound is still present.

Immediately notify the patient's physician.

Validate the data by asking a coworker to listen to the breath sounds.

Document the sound exactly as it was heard.

Answer and Explanation

The Correct Answer is C

A. Assess again in 20 minutes to note whether the sound is still present:
Delaying reassessment without validating the data may result in missing an important clinical finding that requires immediate attention.

B. Immediately notify the patient's physician:
Not appropriate unless the data has been validated. Calling the physician with uncertain information could result in miscommunication.

C. Validate the data by asking a coworker to listen to the breath sounds:
The correct action. When unsure, the nurse should confirm findings to ensure accuracy and safe decision-making.

D. Document the sound exactly as it was heard:
Documentation should be accurate, but if the nurse is unsure, they should validate the finding first before recording it.

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Free Nursing Study Resources

Correct Answer is ["A","D","E"]

Explanation

A. Protection from bacterial intrusion:
The skin is a first-line defense against infection.

B. Increasing dehydration through water loss:
Incorrect. The skin prevents excess water loss; it is a barrier, not a source of dehydration.

C. Decreasing the wastes excreted:
Incorrect. Skin helps excrete wastes (e.g., urea, salts), not reduce excretion.

D. Regulation of body temperature:
Skin sweats and vasodilates/vasoconstricts to maintain thermal balance.

E. Support of wound healing:
Skin contains cells involved in tissue regeneration and repair.

A. "You will require an urgent mammogram" B. "This is quite common to have slight asymmetry in size" C. "This signifies a growth in the left breast" D. "I will inform the physician right away"

Correct Answer is B

Explanation

A. "You will require an urgent mammogram":
Not warranted unless there is a sudden or recent asymmetry, mass, or skin change.

B. "This is quite common to have slight asymmetry in size":
Breast asymmetry is normal and common unless accompanied by new findings or rapid change.

C. "This signifies a growth in the left breast":
This is an assumption-size difference alone does not indicate pathology.

D. "I will inform the physician right away":
Not necessary unless there are abnormal associated signs (e.g., dimpling, mass, discharge).

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When listening to a patient's breath sounds, the nurse is unsure of a sound that is heard. The nurse's next action should be to:

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Naxlex Comprehensive Predictor Exams

Which protective and adaptive function does the skin have? (Select all that apply.)

Correct Answer is ["A","D","E"]

Explanation

When performing a female breast examination, the nurse notes the left breast to be larger than the right. What should the nurse tell the patient?

Correct Answer is B

Explanation

During a cardiovascular assessment, the nurse knows that a thrill is:

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Expert nurses assess and make decisions through the use of:

Which question would be most important to ask an 82-year-old patient during a functional assessment, who has just recently suffered a stroke?

How should the nurse assess the carotid pulse?