Which statement by the nurse indicates the correct order of steps to take when performing a focused assessment of the respiratory system?

"I would palpate, inspect, percuss, and the auscultate.”

"I would percuss, palpate, auscultate, and then inspect.”

"I would auscultate, inspect, percuss, and then palpate."

"I would inspect, auscultate, palpate, and then percuss."

"I would inspect, palpate, percuss, then auscultate.”

Answer and Explanation

The Correct Answer is E

A. Palpate, inspect, percuss, and then auscultate is not the correct order, as inspection is always performed first.
B. Percuss, palpate, auscultate, and then inspect is incorrect, as inspection should come first.
C. Auscultate, inspect, percuss, and then palpate is also incorrect, as auscultation is typically the last step.
D. Inspect, auscultate, palpate, and then percuss is close but does not follow the standard order.
E. Inspect, palpate, percuss, then auscultate is the correct order for respiratory assessment, allowing for a thorough and systematic approach.

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Correct Answer is E

Explanation

A. Providing care based on predetermined criteria may overlook individual client needs and cultural nuances.
B. Prioritizing hospital unit workflow may not align with the individual needs of clients.
C. Care aligned with professional healthcare values may not address the specific cultural values and preferences of diverse clients.
D. This approach may dismiss the client's autonomy and unique cultural context.
E. Honoring the client's differences and perspectives indicates a commitment to culturally responsive care, recognizing and respecting diverse backgrounds.

A. S1 and S2 heard with diaphragm of stethoscope B. A blowing sound heard over the mitral area with the bell of the stethoscope C. Apical pulse palpated at 5th intercostal space, midclavicular line D. Absent sound over carotid arteries with bell of the stethoscope

Correct Answer is B

Explanation

A. S1 and S2 heard with the diaphragm of the stethoscope is a normal finding, as these are the expected heart sounds.
B. A blowing sound heard over the mitral area with the bell of the stethoscope suggests a possible murmur, which could indicate valvular abnormalities and is considered abnormal.
C. Apical pulse palpated at the 5th intercostal space, midclavicular line is normal and expected in adults.
D. Absence of sound over carotid arteries with the bell of the stethoscope indicates no bruits and is considered normal.

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Which statement by the nurse indicates the correct order of steps to take when performing a focused assessment of the respiratory system?

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Naxlex Comprehensive Predictor Exams

A nurse is providing care to a culturally diverse population. Which action indicates the nurse is successful in the role of providing culturally responsive care?

Correct Answer is E

Explanation

The nurse is performing a focused cardiovascular assessment on a 70-year-old client. What finding would be considered abnormal? No palpable vibration felt over the precordium (chest wall)

Correct Answer is B

Explanation

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