The student nurse is preparing to auscultate the client's lungs during the initial assessment. The student nurse is being assisted by the experienced nurse

Question

Which of the following statements by the student nurse indicate the need for further education? 1. "I should think about how loud the auscultated sound is, the tone of the sound, and how long it lasts.".
2. "I should leave the client's television on during the assessment to make the client feel relaxed and comfortable during the assessment.".
3. "I have to remember to keep the client warm during this part of the assessment.".
4. "I cannot listen through the client's gown.".

Answer 1

2
Rationale 1: The student nurse should note the intensity, pitch, and duration of the auscultated sound. Auscultating body sounds requires a quiet environment in which the nurse can listen not just for the presence or absence of sounds, but also for the characteristics of each sound.
Rationale 2: External distractions such as radios, televisions, and loud equipment should be eliminated whenever possible.
Rationale 3: The student nurse should ensure that the client remains warm during this part of the assessment because shivering can impair the nurse's ability to hear the sound well. The nurse cannot listen through gowns or drapes.
Rationale 4: The student nurse should place the stethoscope firmly over the area to be auscultated.