When systematically auscultating a client’s anterior breath sounds, the nurse should begin by placing the stethoscope over which location?
Clavicle.
Lung apex.
Aortic site.
Sternum.
The Correct Answer is B
Choice A rationale
Placing the stethoscope over the clavicle is not the correct starting point for systematically auscultating anterior breath sounds.
Choice B rationale
The nurse should begin by placing the stethoscope over the lung apex, which is located just above the clavicle. This ensures a systematic approach to auscultation.
Choice C rationale
The aortic site is not relevant for auscultating breath sounds; it is used for cardiac auscultation.
Choice D rationale
Placing the stethoscope over the sternum is not the correct starting point for auscultating breath sounds.
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Correct Answer is C
Explanation
Choice A rationale: Administering the prescribed morphine sulfate is important for managing the client’s severe pain. However, the priority action is to assess the neurovascular status of the affected limb to ensure there is no compromise
in circulation or nerve function.
Choice B rationale: Preparing the cast cart for immobilization is necessary to stabilize the fracture. However, before immobilization, it is crucial to perform a neurovascular assessment to identify any potential complications that may need
immediate attention.
Choice C rationale: Performing a neurovascular assessment of the right hand is the priority action. The client’s capillary refill time is prolonged (4 seconds), indicating potential compromised circulation. Assessing the neurovascular status will help determine if there is an urgent need for intervention to prevent further complications such as compartment
syndrome.
Choice D rationale: Initiating the IV infusion of 0.9% sodium chloride is important for maintaining hydration and ensuring venous access. However, the immediate priority is to assess the neurovascular status of the affected limb to identify any urgent issues that need to be addressed.
Correct Answer is B
Explanation
Choice A rationale
Asking if the client has been sleeping well is important for assessing overall health and identifying potential sleep disorders, but it may not directly address the immediate concerns related to the client’s expressionless facial affect, slurred speech, and red conjunctivae.
Choice B rationale
Asking if the client has ever had problems with blood sugar is crucial, as these symptoms could be indicative of hypoglycemia or hyperglycemia. Blood sugar imbalances can cause neurological symptoms such as slurred speech and changes in facial expression.
Choice C rationale
Asking if the client has had anything to eat in the last 24 hours is relevant for assessing nutritional status and potential hypoglycemia, but it may not provide immediate insight into the underlying cause of the symptoms.
Choice D rationale
Asking if the client has been depressed lately is important for assessing mental health, but it may not directly address the immediate physical symptoms the client is experiencing.