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

Choice A rationale
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, the nurse should continue with the remainder of the client’s physical assessment.
Choice B rationale
Reporting the client’s lung sounds to the healthcare provider is unnecessary because vesicular breath sounds are normal and do not indicate any abnormality.
Choice C rationale
Asking the client to cough and then auscultate at the site again is not required since vesicular breath sounds are normal and do not indicate any need for further immediate assessment.
Choice D rationale
Measuring the client’s oxygen saturation with a pulse oximeter is not necessary in this context because the vesicular breath sounds indicate normal lung function.

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Correct Answer is B

Explanation

Choice A rationale
A 75-year-old with a pneumothorax and a chest tube may have a displaced PMI due to the pneumothorax, but it is not necessarily difficult to locate. The chest tube may also cause some displacement, but it is not the primary factor affecting PMI location.
Choice B rationale
A 54-year-old who is 5 feet (152.4 cm) tall and weighs 300 pounds (136.1 kg) is likely to have difficulty locating the PMI due to the increased adipose tissue. Obesity can make it challenging to palpate the PMI as the excess tissue can obscure the heart’s apex.
Choice C rationale
A 2-year-old who is demonstrating diaphragmatic breathing may have a PMI that is slightly higher and more medial than in adults, but it is generally not difficult to locate.
Choice D rationale
A 45-year-old long-distance runner with a body mass index (BMI) of 18 kg/m² is likely to have a more prominent PMI due to a leaner body composition and a potentially enlarged heart from athletic conditioning.

A. Intranasal edema and swelling of turbinates. B. Purulent secretions from eyes and nares. C. Snoring and bilateral, pale gray nodules. D. Eye tearing and thick yellow nasal drainage.

Correct Answer is A

Explanation

Choice A rationale
Intranasal edema and swelling of turbinates are classic signs of allergic rhinitis. Allergic rhinitis is an inflammatory response to allergens, leading to swelling and congestion in the nasal passages. The turbinates, which are structures inside the nose that help filter and humidify the air, become swollen due to the inflammatory response, causing symptoms such as nasal congestion, runny nose, and sneezing.
Choice B rationale
Purulent secretions from the eyes and nares are more indicative of an infection, such as bacterial sinusitis or conjunctivitis, rather than allergic rhinitis. Allergic rhinitis typically involves clear, watery secretions rather than purulent (pus-like) discharge.
Choice C rationale
Snoring and bilateral, pale gray nodules are suggestive of nasal polyps, which can occur in chronic rhinosinusitis but are not specific to allergic rhinitis. Nasal polyps are non-cancerous growths that can obstruct nasal passages and cause breathing difficulties.
Choice D rationale
Eye tearing and thick yellow nasal drainage are more characteristic of an infection, such as bacterial sinusitis or conjunctivitis. Allergic rhinitis usually causes clear, watery secretions and may involve eye symptoms like itching and tearing, but not thick yellow drainage.

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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?

Nursing Test Bank

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Explanation

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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?