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

Clavicle.

Lung apex.

Aortic site.

Sternum.

Answer and Explanation

The Correct Answer is B

Choice A rationale
Placing the stethoscope over the clavicle is not the correct starting point for systematically auscultating anterior breath sounds.
Choice B rationale
The nurse should begin by placing the stethoscope over the lung apex, which is located just above the clavicle. This ensures a systematic approach to auscultation.
Choice C rationale
The aortic site is not relevant for auscultating breath sounds; it is used for cardiac auscultation.
Choice D rationale
Placing the stethoscope over the sternum is not the correct starting point for auscultating breath sounds.

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Correct Answer is A

Explanation

Choice A rationale
Assessing the client's sleep patterns can help determine if fatigue or lack of sleep might be contributing to their symptoms of expressionless facial affect, slurred speech, and red conjunctivae. Poor sleep can lead to various physical and cognitive issues that might explain the client's current presentation.
Choice B rationale
Asking about blood sugar issues is also important, but it might not be the first question to ask given the symptoms. Blood sugar imbalances can cause slurred speech and altered mental status, but it's more common to address general factors like sleep first.
Choice C rationale
Asking if the client has had anything to eat in the last 24 hours is relevant for assessing nutritional status and potential hypoglycemia, but it may not provide immediate insight into the underlying cause of the symptoms.
Choice D rationale
Asking if the client has been depressed lately is important for assessing mental health, but it may not directly address the immediate physical symptoms the client is experiencing.

A. Cornea are jaundiced. B. Face is flushed and diaphoretic. C. Oral mucosa is cyanotic. D. Eyelids are matted and crusted.

Correct Answer is C

Explanation

Choice A rationale
Jaundiced corneas indicate liver dysfunction or other serious conditions that require medical attention, but they do not require immediate intervention compared to cyanosis.
Choice B rationale
A flushed and diaphoretic face can indicate fever, heat exhaustion, or other conditions, but it is not as immediately life-threatening as cyanosis.
Choice C rationale
Cyanotic oral mucosa indicates a lack of oxygen in the blood, which is a medical emergency requiring immediate intervention.
Choice D rationale
Matted and crusted eyelids can indicate an eye infection or other conditions, but they do not require immediate intervention compared to cyanosis.

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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

The nurse is performing an initial assessment of a client who has an expressionless facial affect, slurred speech, and red conjunctivae. Which querry should the nurse ask first?

Correct Answer is A

Explanation

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

Correct Answer is C

Explanation

While completing an admission assessment, the nurse is unable to palpate the client’s left dorsalis pedis (DP) pulse. Which intervention is most important for the nurse to implement?

During the admission assessment, a client admitted with chest pain reports having no breathing problems and no trouble sleeping at night. To obtain further data regarding possible orthopnea, which action should the nurse take?

An older male client reports to the nurse that his feet are cold. Before covering the client’s feet, which assessment(s) should the nurse complete? Select all that apply.

The nurse asks a female client about the proverb “Glass Houses,” and she replies, “It will break the windows.”. Which conclusion should be documented about this client’s response?

The nurse should anticipate difficulty locating the point of maximal impulse (PMI) in which client?

While assessing the legs of an adult client, the nurse observes leathery-looking skin. The client reports aching, tired legs that swell if standing for long periods of time. To screen for venous insufficiency, the nurse should ask the client if they have experienced which subjective finding?

When performing a neurologic assessment on an alert client, the nurse observes that the client’s pupils are both round, 3 mm in size, and respond briskly to light. Which notation should the nurse use when documenting the assessment?