While auscultating a client's breath sounds, the nurse hears vesicular sounds in the bases of both lungs posteriorly. Which action should the nurse take in response to this finding?

Continue with the remainder of the client's physical assessment.

Report the client's abnormal lung sounds to the healthcare provider.

Ask the client to cough and then auscultate at the site again.

Measure the client's oxygen saturation with a pulse oximeter.

Answer and Explanation

The Correct Answer is A

A) Continue with the remainder of the client's physical assessment:
Vesicular breath sounds are normal breath sounds heard over the peripheral lung fields. Hearing vesicular sounds in the bases of both lungs posteriorly indicates normal air movement in the lungs. Therefore, there is no immediate concern or need for further action related to this finding. The nurse should continue with the remainder of the client's physical assessment.

B) Report the client's abnormal lung sounds to the healthcare provider:
Vesicular breath sounds are considered normal lung sounds and do not warrant reporting as abnormal. Reporting this finding to the healthcare provider would not be appropriate and may lead to unnecessary concern or intervention.

C) Ask the client to cough and then auscultate at the site again:
Coughing would not be necessary in response to hearing vesicular breath sounds, as these are normal lung sounds. Repeating the auscultation may not provide additional information beyond confirming the presence of normal breath sounds.

D) Measure the client's oxygen saturation with a pulse oximeter:
Measuring oxygen saturation with a pulse oximeter is not indicated in response to hearing vesicular breath sounds. These breath sounds are normal and do not necessarily indicate a problem with oxygenation. Therefore, measuring oxygen saturation would not be the appropriate action in this situation.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is ["C","D","E"]

Explanation

Answer: C. Age when the client started smoking.
Knowing when the client began smoking is essential for determining the total duration of smoking. This information allows the nurse to calculate how long the client has been exposed to tobacco, which is critical for assessing potential health risks associated with their smoking history.

D. Packs of cigarettes smoked per day.
This information is crucial as it directly contributes to the calculation of pack years. Understanding how many packs the client smokes each day helps quantify their level of tobacco exposure. For instance, smoking one pack per day for ten years results in ten pack years, while two packs per day over the same period would lead to twenty pack years.

E. Number of years the client smoked.
This detail is necessary to determine the total duration of the smoking habit. The total number of years smoked, combined with the daily pack consumption, provides a comprehensive view of the client's smoking history. It allows the nurse to assess the cumulative risk associated with long-term tobacco use, which is important for evaluating the client’s health and potential interventions.

Rationale for Options Not Selected:

A. Number of attempts to quit smoking.
While this information can provide insight into the client's motivation and efforts to quit, it is not relevant for calculating pack years. Pack years focus specifically on the amount and duration of smoking, rather than attempts to quit, which may be useful in assessing readiness for cessation interventions but does not factor into the calculation of exposure.

B. Client's current age.
Although the client's age can provide context regarding their smoking history, it is not necessary for the actual calculation of pack years. Instead, it is the age when the client started smoking, along with the total years smoked and the number of packs smoked per day, that are critical for this specific assessment. The current age is not needed to compute pack years directly.

Summary of Calculation:

To calculate pack years, use the formula:

Pack Years = (Number of packs smoked per day) × (Number of years smoked)

For example, if a client smoked 1 pack per day for 20 years, they would have 20 pack years. If they smoked 2 packs a day for the same period, that would equate to 40 pack years. This measurement is essential for understanding the health risks associated with smoking and guiding further assessment and intervention strategies.

A. Dimpled area above anus. B. Flap of tissue at sphincter. C. Increased pigmentation and coarse skin. D. Hypotonic tone of the anal sphincter.

Correct Answer is C

Explanation

A) Dimpled area above anus:
This finding may indicate a pilonidal cyst, which is an abnormality rather than a normal appearance of the anus.

B) Flap of tissue at sphincter:
A flap of tissue at the anal sphincter, also known as the anal valve, is a normal anatomical feature. It helps maintain continence and prevents leakage of stool.

C) Increased pigmentation and coarse skin:
Increased pigmentation and coarse skin may be typical findings in the perianal area due to factors such as friction, moisture, or aging. While not everyone will have this appearance, it is within the range of normal variations.

D) Hypotonic tone of the anal sphincter:
Hypotonic tone of the anal sphincter may suggest weakness or dysfunction of the anal sphincter, which is not considered a normal finding.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

While auscultating a client's breath sounds, the nurse hears vesicular sounds in the bases of both lungs posteriorly. Which action should the nurse take in response to this finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While obtaining a client's health history related to smoking cigarettes, the nurse plans to determine the client's smoking pack years. What information should the nurse obtain for this calculation? Select all that apply.

Correct Answer is ["C","D","E"]

Explanation

Summary of Calculation:

While completing an admission assessment for a client with gastrointestinal bleeding, the nurse inspects the perianal area and anus. Which findings indicate a normal appearance of the anus?

Correct Answer is C

Explanation

An older adult male arrives at the healthcare center with lower abdominal discomfort and frequent urination. The nurse asks the client to provide a urine sample. After an extended period of time, the client returns with only a few drops of urine. Which action should the nurse implement?

An adult client presents with gnawing epigastric pain. The pain is worse when the client is hungry and abates after eating something. Which problem do these symptoms suggest?

The nurse is examining an older female client and suspects that she has a dysfunction in her hip region. Which procedure should the nurse perform to further assess for hip dysfunction?

When inspecting the client's skin, the nurse observes several areas of ecchymosis on the trunk and extremities. Which information in the client's history requires additional follow-up by the nurse?

While completing an admission assessment, the nurse is unable to palpate the client's left dorsalis pedis (DP) pulse. Which intervention is most important for the nurse to implement?

When performing a neurologic assessment on an alert client, the nurse observes that the client's pupils are both round, 3 mm in size, and respond briskly to light. Which notation should the nurse use when documenting the assessment?

While auscultating a client's abdomen, the nurse hears a low-pitched blowing sound in the upper midline area. Which is the likely indication of this finding?

While performing a physical assessment, the nurse is unable to palpate the client's pedal pulses. Which action should the nurse take?