The nurse is observing the lung auscultation technique of a student nurse. What is the correct method to use when progressing from one auscultatory site to another?
Posterior to anterior comparison
Side-to-side comparison
Interspace-by-interspace comparison
Proximal to distal comparison
Top-to-Bottom comparison
The Correct Answer is B
A. While posterior to anterior comparisons are used, they do not encompass the entire technique for auscultation.
B. Side-to-side comparison is the correct method as it allows for immediate assessment of differences between lung fields and helps to identify abnormal sounds effectively.
C. Interspace-by-interspace comparison is not a commonly recognized term for this method and can lead to confusion in technique.
D. Proximal to distal comparison is not specific to lung auscultation and does not effectively apply to lung assessment.
E. Top-to-bottom comparison may miss abnormalities in a specific region of the lungs; side-to-side is preferred.
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Correct Answer is E
Explanation
A. Calling another nurse for help is unnecessary unless additional assistance is required after initial interventions.
B. Giving pain medication as ordered may address the chest pain but does not address the immediate need for oxygenation.
C. Calling the admitting healthcare provider can be done later if symptoms do not improve, but the immediate priority is to improve oxygenation.
D. Telling the client to remain calm may help reduce anxiety but does not address the low oxygen saturation.
E. Applying oxygen via nasal cannula as ordered is the priority action to improve the client’s oxygen saturation and alleviate hypoxemia, which could be contributing to their chest pain.
Correct Answer is C
Explanation
A. "Leave" is not a part of the LEARN mnemonic.
B. "Leverage" is also not included in the LEARN mnemonic.
C. "Listen" is the correct answer; it encourages active listening to understand the client’s cultural needs and perspectives.
D. While "Look" may imply observation, it is not a component of the LEARN mnemonic.
E. "Liken" is not part of the LEARN mnemonic and is not relevant here.