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 B
Explanation
Choice A rationale
Asking the client to describe any other related symptoms is important for a comprehensive assessment but does not objectively confirm the presence of fever.
Choice B rationale
Placing the dorsum of the hand on the client’s forehead is a quick and practical method to assess for fever. It provides an initial subjective assessment of the client’s temperature before taking an accurate measurement with a thermometer.
Choice C rationale
Using both hands to hold and palpate the client’s hands may help assess for other symptoms such as clamminess or coldness but does not objectively confirm the presence of fever.
Choice D rationale
Lightly pinching a fold of skin over the client’s sternum assesses skin turgor and hydration status but does not objectively confirm the presence of fever.
Correct Answer is D
Explanation
Choice A rationale
Fissuring refers to deep cracks or splits in the skin. While it can occur in various skin conditions, it is not a typical manifestation of an allergic reaction to an insect bite.
Choice B rationale
Excoriation refers to a scratch or abrasion on the surface of the skin, often resulting from scratching due to itching. While this can occur secondary to an allergic reaction, it is not a primary characteristic of such reactions.
Choice C rationale
Papules are small, raised, solid bumps on the skin that are typically less than 1 centimeter in diameter. They can be a result of various skin conditions, but they are not specifically associated with allergic reactions to insect bites.
Choice D rationale
Wheals, also known as hives or urticaria, are raised, red or skin-colored welts on the skin that often itch and can appear rapidly in response to an allergen such as an insect bite. They are a characteristic feature of allergic reactions and are caused by the release of histamine.