When assessing lung sounds, the nurse applies the chest piece to the client's upper back, but avoids placing it over the scapulae or ribs. How does this intervention help in the assessment?
A) Helps to clear the air passages and open the alveoli.
B) Reduces sound from air turbulence and prevents hyperventilation.
C) Minimizes pain or discomfort to the client.
D) Facilitates hearing sounds in the upper and lower lobes.
D
Feedback:
The nurse should avoid placing the chest piece over the scapulae or ribs when applying the chest piece to the upper back in order to facilitate hearing sounds in the upper and lower lobes. If crackles and gurgles are audible during the assessment, the nurse may ask the client to cough or breathe deeply, as doing so helps to clear the air passages and open the alveoli. The nurse instructs the client to breathe in and out through an open mouth, deeply but slowly, in order to reduce the sound from air turbulence and to prevent hyperventilation. This placement does not avoid discomfort to the client.
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