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.”
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. A respiratory rate of 20 is within the normal range for adults (12-20 breaths per minute), especially in someone experiencing dyspnea.
B. Vesicular sounds in the lung periphery are normal findings, particularly in healthy lung areas.
C. A capillary refill time of 5 seconds indicates poor perfusion and could suggest systemic issues or hypoxia, which is concerning in a patient with dyspnea.
D. An anteroposterior (AP) diameter of 1:2 is normal; a barrel chest might indicate chronic respiratory conditions but is not an immediate concern in this context.
E. Equal chest expansion is a normal finding and indicates effective respiratory mechanics.
Correct Answer is A,E,D,F,C,B
Explanation
Unoxygenated blood flows from the body into the right atrium, then passes through the pulmonary artery to the lungs. After receiving oxygen in the lungs, blood flows back to the heart via the pulmonary vein into the left atrium. It then moves into the left ventricle and is finally pumped out to the body through the aorta.
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