When auscultating the lungs of an adult client, the nurse notes that low-pitched, soft breath sounds are heard over the lower lobes. How would the nurse interpret these findings?
Normal sounds auscultated up against the sternum
Bronchovesicular sounds that are normal over that location
Bronchial sounds that are normal over that location
Normal sounds auscultated over the trachea
Vesicular breath sounds that are normal in that location
The Correct Answer is E
A. Normal sounds against the sternum would not be low-pitched or soft; they would typically be more pronounced.
B. Bronchovesicular sounds are medium-pitched and are not expected in the lower lobes; they are usually heard in the central area.
C. Bronchial sounds are high-pitched and hollow, typically heard over the trachea, not in the lower lobes.
D. Normal sounds over the trachea would not be described as low-pitched or soft.
E. Vesicular breath sounds are soft, low-pitched, and normal over peripheral lung fields, including the lower lobes, making this the correct interpretation.
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Correct Answer is E
Explanation
A. Providing care based on predetermined criteria may not be responsive to the unique cultural needs of each client.
B. Focusing solely on hospital unit workflow prioritizes efficiency over individualized patient care, which may not respect cultural differences.
C. This approach fails to acknowledge the diverse values and beliefs of clients, which can lead to miscommunication and unmet needs.
D. This implies a top-down approach to care, which may disregard the client’s preferences and cultural context.
E. Honoring the client's differences and perspectives demonstrates the nurse's commitment to culturally responsive care, ensuring that care is tailored to meet the unique needs of each client.
Correct Answer is B
Explanation
A. Using the incentive spirometer is primarily aimed at preventing respiratory complications, not directly related to DVT prevention.
B. Dangling the legs off the bed promotes blood flow and prepares the client for ambulation, which helps prevent venous stasis and reduces the risk of DVT.
C. Encouraging ambulation is crucial for DVT prevention, but this task typically requires nursing judgment and assessment.
D. Keeping the knees elevated for prolonged periods may increase the risk of venous stasis, potentially contributing to DVT formation.
E. Limiting fluids without a clinical indication can lead to dehydration, which may increase the risk of blood clots.