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 D

Explanation

A. Tympany indicates the presence of gas within the intestines. This would not be expected over the liver area if there is hepatomegaly.
B. This is not an expected finding in hepatomegaly. Tympany is associated with air-filled structures, which would not be present over an enlarged liver.
C. A hollow sound is also indicative of air-filled organs like the intestines. It is not a sign of hepatomegaly, which would be characterized by dullness on percussion.
D. Dullness upon percussion outside the costal margins suggests an enlarged liver (hepatomegaly). This is due to the liver becoming larger and filling the space that normally contains air-filled organs like the intestines.

A. Document this finding in the medical record. B. Ask if the client recently received any antibiotics. C. Ask the client about use of irritating chemical agents. D. Schedule an appointment with a dermatologist.

Correct Answer is A

Explanation

A. Documenting the finding is important to ensure proper record-keeping, especially in clients with dark pigmented skin, where some variations in skin tone may be normal.
B. Asking about antibiotics is unnecessary unless there's suspicion of a drug-induced reaction or side effect.
C. While use of irritating chemicals could cause changes, this scenario does not directly suggest that as the cause.
D. Referral to a dermatologist is not required without further investigation to determine if the discoloration is concerning.

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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 completing an admission assessment for a client with fatigue, weakness, and unexplained weight loss, the nurse notes scleral jaundice. Which finding during percussion of the abdomen should the nurse document indicating hepatomegaly?

Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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