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 benign variation would not typically present with a pattern of dullness extending from the 5th left intercostal space to the 2nd left intercostal space at the sternal border. This pattern suggests an abnormality rather than a benign variation.
Choice B rationale
Cardiac enlargement is indicated by an area of dullness extending from the 5th left intercostal space to the 2nd left intercostal space at the sternal border. This finding suggests an enlarged heart, which can be due to conditions such as cardiomegaly or left ventricular hypertrophy.
Choice C rationale
Cardiac atrophy refers to a decrease in the size or mass of the heart muscle, resulting in a smaller than normal heart. The described findings indicate dullness extending upward, suggesting an enlargement rather than atrophy of the heart.
Choice D rationale
An expected finding would not typically present with the described pattern of dullness. The normal area of cardiac dullness is more limited and does not extend as described.

A. Recent over-the-counter infection cures. B. Number of indoor cats at home. C. Nontender firm lymph nodes. D. Amount of daily caffeine consumption.

Correct Answer is C

Explanation

Choice C rationale
Nontender firm lymph nodes are a significant finding that may indicate a more serious underlying condition, such as malignancy. This information is crucial for the healthcare provider to determine the next steps in diagnosis and treatment.
Choice A rationale
Recent over-the-counter infection cures are less relevant compared to the physical characteristics of the lymph nodes when assessing for potential malignancy.
Choice B rationale
The number of indoor cats at home is not directly related to the assessment of enlarged lymph nodes in the axilla.
Choice D rationale
The amount of daily caffeine consumption is not relevant to the assessment of enlarged lymph nodes in the axilla.

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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

Naxlex Comprehensive Predictor Exams

While percussing the borders of the heart, the nurse picks up an area of dullness beginning at the 5th left intercostal space and moving upward to the 2nd left intercostal space at the sternal border. What do these findings indicate?

Correct Answer is B

Explanation

The nurse is examining a female client who states she has no complaints, so has not had a physical examination for over 5 years. The nurse palpates enlarged lymph nodes in the axilla. Which finding is most important for the nurse to describe when reporting to the healthcare provider?

Correct Answer is C

Explanation

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