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.

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

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

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 and expected over the lung bases, so the nurse should continue the assessment.

B. Ask the client to cough and then auscultate at the site again. This action is unnecessary as vesicular breath sounds are normal.

C. Report the client's abnormal lung sounds to the healthcare provider. This is incorrect as vesicular breath sounds are not abnormal.

D. Measure the client's oxygen saturation with a pulse oximeter. There is no indication of abnormal breath sounds or respiratory distress, so this action is unnecessary.

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Correct Answer is A

Explanation

A. Use a Doppler to assess an audible DP pulse. This is the most immediate and effective intervention to locate a pulse that is not palpable. A Doppler device can detect blood flow that is not perceptible by palpation.

B. Assess capillary refill distal to the DP pulse. While assessing capillary refill can provide information about peripheral circulation, it does not help locate the pulse.

C. Review client's history for vascular disease. This is important for understanding the client's overall health, but it is not an immediate intervention to locate the pulse.

D. Place a mark where DP pulse is auscultated. Marking the pulse location can be helpful once the pulse is found, but it is not an intervention to find an initially absent pulse.

A. Cool, pale skin below the knees. B. Deep, continuous pain in the calf muscles. C. Decreased pain when legs are elevated. D. Painful symptoms alleviated by warmth.

Correct Answer is C

Explanation

A. Cool, pale skin below the knees. This suggests arterial insufficiency rather than venous insufficiency.

B. Deep, continuous pain in the calf muscles. This suggests deep vein thrombosis (DVT) rather than chronic venous insufficiency.

C. Decreased pain when legs are elevated. This is the best choice as elevation typically relieves symptoms of venous insufficiency by reducing venous pressure.

D. Painful symptoms alleviated by warmth. This is less specific to venous insufficiency and more indicative of muscle or joint issues.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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