Which assessment requires the nurse to assess the patient further?

A. Listening as the patient inhales and then going to the next site during exhalation. This method does not allow for a complete assessment of breath sounds, as abnormalities may be present during either phase of respiration.
B. If the patient is modest, listening to sounds over his or her clothing or hospital gown. Clothing can muffle or distort breath sounds, leading to inaccurate assessments. The stethoscope should be placed directly on the skin.
C. Instructing the patient to breathe in and out rapidly while listening to the breath sounds. Rapid breathing may lead to hyperventilation and dizziness, and it can make it difficult to detect subtle abnormalities such as crackles or wheezes.
D. Listening to at least one full respiration in each location. This is the correct technique because it allows the nurse to fully assess breath sounds during both inhalation and exhalation, ensuring accurate identification of any abnormal sounds.

A. Check the patient's apical rate to check for a pulse deficit. While an apical pulse assessment may be useful later, the priority in a sudden drop in blood pressure with signs of fainting is to ensure adequate circulation by checking a central pulse.
B. Immediately check the client's carotid pulse. A significant blood pressure drop (132/82 to 104/52), pale skin, and signs of fainting suggest possible shock or circulatory collapse. The carotid pulse should be checked immediately to assess perfusion.
C. Elevate the head of the patient's bed to at least 45 degrees. Raising the head of the bed could worsen hypotension and decrease blood flow to the brain, increasing the risk of syncope. The Trendelenburg position or lying flat may be more appropriate.
D. Report the findings to the health care provider immediately. While the provider should be notified, the priority action is to assess circulation by checking the carotid pulse first before escalating care.