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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Correct Answer is D

Explanation

A. Ask the patient about a history of frostbite:
Frostbite is one possible cause, but not the first priority. Investigation should begin more broadly.

B. Consider this a normal capillary refill time that requires no further assessment:
Incorrect. Normal capillary refill is < 2 seconds. 5 seconds is delayed.

C. Suspect that the patient has venous insufficiency:
Capillary refill tests arterial perfusion, not venous status.

D. Consider this a delayed capillary refill time, and investigate further:
A refill >2 seconds may indicate peripheral arterial disease, hypothermia, or shock, and warrants further assessment.

A. "Stopping your dependence on cigarettes can be very difficult. I understand how you feel." B. "I'd quit if I were you. The doctor really knows what he is talking about." C. "Why are you confused? Didn't the doctor give you the information about the smoking cessation program we offer?" D. "Would you like some information about the different ways a person can quit smoking?"

Correct Answer is D

Explanation

A. "Stopping your dependence on cigarettes can be very difficult. I understand how you feel.":
Shows empathy but does not guide the patient toward the next step or offer a solution.

B. "I'd quit if I were you. The doctor really knows what he is talking about.":
Judgmental and authoritative, lacks therapeutic communication.

C. "Why are you confused? Didn't the doctor give you the information about the smoking cessation program we offer?":
Dismissive and confrontational, could make the patient feel criticized.

D. "Would you like some information about the different ways a person can quit smoking?":
Encourages patient involvement and supports informed decision-making, a core principle of patient education.

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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

The nurse is assessing a 64-year-old patient whose vital signs are normal, with a capillary refill time of 5 seconds. What should the nurse do next?

Correct Answer is D

Explanation

During a visit to the clinic, a patient states, "The doctor just told me he thought I ought to stop smoking. He doesn't understand how hard I've tried. I just don't know the best way to do it. What should I do?" The nurse's most appropriate response in this case would be:

Correct Answer is D

Explanation

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