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When systematically auscultating a client’s anterior breath sounds, the nurse should begin by placing the stethoscope over which location?

A.

Clavicle.

B.

Lung apex.

C.

Aortic site.

D.

Sternum.

Answer and Explanation

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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View Related questions

Correct Answer is D

Explanation

Choice A rationale

Palpating the area for masses may be indicated if there are other signs or symptoms suggestive of abdominal pathology, but a depressed umbilicus alone is not typically an indication for palpation.

Choice B rationale

Observing the midline for scarring may be relevant if there are signs of previous surgical procedures or other abdominal interventions, but the presence of a depressed umbilicus does not necessarily indicate scarring or previous surgery.

Choice C rationale

Asking about recent abdominal trauma could potentially cause changes in the appearance of the umbilicus, such as bruising or swelling, but it is not the most likely explanation for a depressed umbilicus below the surface of the abdomen.

Choice D rationale

A depressed umbilicus below the surface of the abdomen is a normal anatomical variation in some individuals, particularly those with a more slender build or a deeper abdominal cavity. It does not typically indicate pathology or require further intervention.

Correct Answer is D

Explanation

Choice A rationale

A BMI of 32 kg/m² is not considered an appropriate weight for height. According to the American Heart Association, a BMI between 18.5 and 24.9 kg/m² is considered normal weight. A BMI of 32 kg/m² falls into the obese category, which indicates excess body fat and potential health risks.

Choice B rationale

While a BMI of 32 kg/m² is classified as obese, it is not categorized as extreme obesity. Extreme obesity is typically defined as a BMI of 40 kg/m² or higher. Therefore, this choice is incorrect.

Choice C rationale

A BMI of 32 kg/m² does not indicate undernutrition or malnutrition. Undernutrition is associated with a BMI of less than 18.5 kg/m². This choice is incorrect as the BMI in question indicates obesity, not undernutrition.

Choice D rationale

A BMI of 32 kg/m² is classified as obese. Obesity is a serious threat to well-being as it increases the risk of various health conditions, including heart disease, diabetes, hypertension, and certain cancers. Therefore, this choice is correct.

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