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
Hypotonic tone of the anal sphincter is an abnormal finding and may indicate neurological or muscular disorders affecting the sphincter control.
Choice B rationale
A dimpled area above the anus can be a sign of a congenital condition such as a pilonidal sinus or other abnormalities.
Choice C rationale
Increased pigmentation and coarse skin around the anus are normal findings and are due to the natural variation in skin texture and color in this area.
Choice D rationale
A flap of tissue at the sphincter, also known as a skin tag, can be a normal finding but may also indicate previous hemorrhoids or other conditions.
Correct Answer is A
Explanation
Choice A rationale: Administering oxygen via nasal cannula is the first priority in this scenario. The client’s oxygen saturation is 88% on room air, which indicates hypoxemia. Providing supplemental oxygen will help improve the client’s oxygenation and alleviate symptoms of shortness of breath. Ensuring adequate oxygenation is crucial to prevent further respiratory distress and potential complications.
Choice B rationale: Obtaining a sputum culture is important to identify the causative organism of the client’s respiratory infection and guide appropriate antibiotic therapy. However, this action is not the immediate priority. Addressing the client’s hypoxemia by administering oxygen takes precedence to stabilize the client’s condition.
Choice C rationale: Administering an antipyretic medication can help reduce the client’s fever and improve comfort. However, this is not the immediate priority. The client’s hypoxemia and respiratory distress need to be addressed first by administering oxygen.
Choice D rationale: Encouraging the client to increase fluid intake is important for maintaining hydration and helping to thin respiratory secretions. However, this action is not the immediate priority. The client’s hypoxemia and respiratory distress need to be addressed first by administering oxygen