Which instruction does the nurse provide to auscultate the adult client's lungs effectively?
1. Take rapid shallow breaths.
2. Breathe with the mouth open.
3. Cough and take a deep breath.
4. Take a deep breath and hold it.
2
2. The nurse instructs the client to breathe with the mouth open because this facili-tates air movement and amplifies client lung sounds. In addition, the nurse instructs the client to take slow, deep breaths; however, the nurse closely observes for ligh-theadedness and fatigue, especially with older clients, caused by hyperventilation.
1. Rapid shallow breaths quickly induce hypocarbia, leading to lightheadedness and fatigue, and impair auscultation of breath sounds because the sounds are too faint to assess.
3. Coughing and deep breathing are instructions to facilitate the mobilization of pul-monary secretions.
4. Holding the breath impairs the nurse's ability to auscultate air movement for a res-piratory assessment.
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