Health Promotion and Disease Prevention (MODULE 2)

A nurse is preparing to auscultate a client's breath sounds. To assess vesicular breath sounds, the nurse places the stethoscope over: - Answer - The peripheral lung fields Rationale: Vesicular breath sounds are heard over the peripheral lung fields, where air flows through the smaller bronchioles and alveoli. Bronchovesicular breath sounds are heard over the major bronchi. Bronchial (tracheal) breath sounds are heard over the trachea and larynx. Breath sounds are not heard over the xiphoid process. A nurse palpates a client's radial pulse, noting the rate, rhythm, and force, and concludes that the client's pulse is normal. Which of the following notations would the nurse make in the client's record to document the force of the client's pulse? - Answer - 2+ Rationale: When assessing a pulse, the nurse should note the rhythm, amplitude, and symmetry of pulses and should compare peripheral pulses on the two sides for rate, rhythm, and quality. A 4-point scale may be used to assess the force (amplitude) of the pulse: 4+, bounding pulse; 3+, increased pulse; 2+, normal pulse; 1+, weak pulse. In this case the nurse would grade the client's pulse as 2+. Performing an abdominal assessment, a nurse auscultates before palpating and percussing the abdomen. The nurse performs the assessment in this manner because: - Answer - Palpation and percussion can increase peristalsis Rationale: When performing an abdominal assessment, the nurse auscultates the abdomen after inspection. Auscultation is done before palpation and percussion because these assessment techniques can increase peristalsis, which would yield a false interpretation of bowel sounds. The other options identify incorrect reasons for auscultating the abdomen before palpating and percussing it. A nurse is preparing to check the breath sounds of a client. Over which anatomic area does the nurse place the stethoscope when auscultating for bronchial breath sounds? - Answer - Rationale: Bronchial (tracheal) breath sounds are located over the trachea and larynx. Bronchovesicular breath sounds are located over major bronchi. Vesicular breath sounds are located over the peripheral lung fields. The upper sternal area is where main bronchi are located. Breath sounds are normally not heard over the cricoid cartilage. A client who was given a diagnosis of hypertension 3 months ago is at the clinic for a checkup. Which type of database does the nurse use in performing an assessment? - Answer - Follow-up