Which assessment finding, obtained during chest auscultation, should the nurse consider a normal finding?

Blowing, hollow sounds above sternum.

Slight crackling throughout lung fields.

Faint whistling over both lung bases.

Right breath sounds louder than left.

Answer and Explanation

The Correct Answer is D

A.   Blowing or hollow sounds above the sternum are abnormal and may suggest a condition like aortic or pulmonary disease. Such sounds are not typical during routine chest auscultation and may indicate pathology like bronchial obstruction or an abnormal vascular sound.
B.   Slight crackling sounds, also known as "rales" or "crackles," may be indicative of fluid accumulation in the lungs, often seen in conditions like pneumonia or congestive heart failure. These are not considered normal findings and warrant further evaluation.
C.   Faint whistling sounds may be indicative of wheezing, which is often a sign of airway narrowing or obstruction, as seen in asthma or chronic obstructive pulmonary disease (COPD). Wheezing is not typically considered normal and should be investigated further.
D.   Right-sided breath sounds being louder than the left could be a normal finding in certain individuals, depending on factors like body position or anatomical variations. In a healthy individual, this difference may not indicate pathology unless associated with other symptoms such as asymmetry in lung sounds or dyspnea.

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Correct Answer is C

Explanation

A. While it is important to palpate the correct quadrant, this is unlikely the cause if the gallbladder cannot be located. The gallbladder is typically located in the right upper quadrant, and the nurse would have been palpating this area. This option does not address the most likely cause.
B. A normal gallbladder might not always be palpable, especially if the client is obese. However, inability to palpate the gallbladder does not necessarily indicate a problem; this is a common finding in obese individuals where fat tissue can obscure the gallbladder.
C. Obesity can make it more difficult to palpate internal structures such as the gallbladder. Excess adipose tissue in the abdominal area can prevent the nurse from feeling the gallbladder during palpation. This is the most likely explanation for the failure to locate the gallbladder.
D. While deeper palpation might be necessary in obese clients, the inability to palpate the gallbladder is more likely due to the obscuring effects of fat, rather than a technique issue. It's a common finding that obesity hinders the ability to palpate organs like the gallbladder.

A. Ask questions in a vague, nonspecific format. B. Share personal values to put the client at ease. C. Begin with questions that are less sensitive in nature. D. Get the most difficult questions over with first.

Correct Answer is C

Explanation

A. While this approach may seem less intrusive, it can create confusion and may prevent the client from feeling fully understood. Asking vague questions could make it more difficult to get useful information about the client's health concerns.
B. Sharing personal values is generally not appropriate in a clinical interview, as it could create boundaries that compromise the professional relationship. The nurse should maintain objectivity and empathy without sharing personal beliefs.
C. Starting with less sensitive questions allows the nurse to build rapport and trust with the client before delving into more personal or difficult topics. This approach is helpful in easing the client into more sensitive discussions.
D. Asking the most difficult questions right away can overwhelm the client, especially if they are hesitant or uncomfortable. It is better to establish a trusting relationship first and allow the client to open up at their own pace.

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Which assessment finding, obtained during chest auscultation, should the nurse consider a normal finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While assessing a client who is obese, the nurse is unable to locate the gallbladder when palpating below the liver margin at the lateral border of the rectus abdominal muscle. Which is the most likely explanation for failure to locate the gallbladder by palpation?

Correct Answer is C

Explanation

Correct Answer is C

Explanation

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