When systematically auscultating a client's anterior breath sounds, the nurse should begin by placing the stethoscope over which location?

Aortic site.

Sternum.

Lung apex.

Clavicle.

Answer and Explanation

The Correct Answer is C

A) Aortic site:
The aortic site is relevant for cardiac assessment but not for auscultating breath sounds.

B) Sternum:
The sternum is a bony structure and not an optimal location to start auscultating breath sounds as it can interfere with sound transmission.

C) Lung apex:
Auscultating at the lung apex, which is located just above the clavicle, is the appropriate starting point for assessing anterior breath sounds. This ensures that the upper parts of the lungs are examined first.

D) Clavicle:
While the area near the clavicle is relevant, it is more precise to refer to the lung apex, which includes the area just above the clavicle, for starting the auscultation of breath sounds.

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Correct Answer is D

Explanation

A) Face is flushed and diaphoretic:
While flushing and diaphoresis can indicate fever, anxiety, or other conditions, they do not typically require immediate intervention unless associated with other severe symptoms.

B) Eyelids are matted and crusted:
Matted and crusted eyelids may indicate an eye infection, such as conjunctivitis, which requires treatment but not immediate emergency intervention.

C) Cornea are jaundiced:
Jaundiced corneas (scleral icterus) suggest elevated bilirubin levels and possible liver dysfunction. This finding requires prompt evaluation but is not typically an emergency requiring immediate intervention.

D) Oral mucosa is cyanotic:
Cyanosis of the oral mucosa indicates a lack of oxygen in the blood and is a sign of hypoxemia or respiratory distress. This is a critical finding that requires immediate intervention to address potential life-threatening respiratory or cardiovascular issues.

A. Initiate NPO status. B. Restrict activity to bed rest. C. Monitor urinary output. D. Obtain an electrocardiogram.

Correct Answer is A

Explanation

A) Initiate NPO status: The client's sudden cessation of breathing during deep palpation of the abdomen suggests peritoneal irritation, which could be indicative of a serious condition such as appendicitis or peritonitis. Initiating NPO (nothing by mouth) status is crucial in case emergency surgery is required to address the underlying abdominal pathology. NPO status helps prevent complications such as aspiration if surgery becomes necessary.

B) Restrict activity to bed rest: While bed rest may be indicated for certain abdominal conditions to reduce discomfort and prevent exacerbation of symptoms, it is not the most immediate priority in this scenario. The priority is addressing the potential need for emergency surgery and ensuring the client's safety.

C) Monitor urinary output: Monitoring urinary output is important for assessing hydration status and renal function, but it is not the most critical intervention in this scenario where peritoneal irritation is suspected.

D) Obtain an electrocardiogram: While an electrocardiogram (ECG) may be warranted in certain situations, such as if the client is experiencing chest pain or symptoms suggestive of cardiac involvement, it is not indicated as the most immediate action in this scenario of acute abdominal pain and potential peritoneal irritation.

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When systematically auscultating a client's anterior breath sounds, the nurse should begin by placing the stethoscope over which location?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While observing a client's face, which assessment finding requires immediate intervention by the nurse?

Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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