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PNC(C) practice questions

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Question 1Health Promotion and Maintenance

A 24-year-old woman at 10 weeks' gestation reports no immunizations since childhood. Which vaccine is safe to administer during pregnancy when indicated?

  1. Measles-mumps-rubella
  2. Live attenuated influenza
  3. Varicella
  4. Tetanus-diphtheria-acellular pertussis Correct answer.

Explanation

Inactivated and toxoid vaccines such as Tdap are considered safe in pregnancy and Tdap is routinely recommended between 27 and 36 weeks to protect the newborn. Live attenuated vaccines are contraindicated because of theoretical fetal infection risk.

Question 2Health Promotion and Maintenance

A newborn's mother is hepatitis B surface antigen positive. In addition to hepatitis B vaccine given within 12 hours of birth, what should the nurse anticipate administering?

  1. Palivizumab
  2. Vitamin K only
  3. Rotavirus vaccine
  4. Hepatitis B immune globulin Correct answer.

Explanation

Infants born to HBsAg-positive mothers need both the vaccine series and hepatitis B immune globulin within 12 hours of birth to prevent perinatal transmission. This combination provides passive and active immunity.

Question 3Health Promotion and Maintenance

A nurse teaches a client about a new prescription for a combined oral contraceptive. Which instruction is most important to include?

  1. Stop the pill whenever a headache occurs
  2. Take the pill at the same time each day Correct answer.
  3. Take the pill only on days of intercourse
  4. Double the dose after any missed pill

Explanation

Consistent daily timing maintains stable hormone levels and maximizes contraceptive effectiveness, especially for progestin-only pills. Clients should also follow package guidance for missed doses rather than improvising.

Question 4Health Promotion and Maintenance

Which finding best indicates that a primigravida is in the latent phase of the first stage of labor?

  1. Cervix dilated 9 cm with urge to bear down
  2. Cervix dilated 3 cm with irregular mild contractions Correct answer.
  3. Complete dilation with active pushing
  4. Delivery of the placenta

Explanation

The latent phase of the first stage extends from onset of labor to about 4 to 6 cm dilation with mild, irregular contractions. Active phase and second and third stages involve greater dilation, pushing, and placental expulsion.

Question 5Health Promotion and Maintenance

A 6-month-old is brought for a well-child visit. Which developmental milestone should the nurse expect to observe?

  1. Copying a circle with a crayon
  2. Walking independently
  3. Sitting with support and rolling over Correct answer.
  4. Using two-word phrases

Explanation

By 6 months most infants can roll over and sit with support, reflecting strengthening trunk control. Independent walking, two-word phrases, and copying shapes occur much later in development.

Question 6Health Promotion and Maintenance

A client at 28 weeks' gestation asks how to perform fetal kick counts. Which instruction is appropriate?

  1. Count only painful movements
  2. Perform counts only after contractions begin
  3. Limit fluid intake before counting
  4. Count movements at the same time daily and report fewer than 10 in 2 hours Correct answer.

Explanation

Daily fetal movement counting helps identify decreased activity that may signal fetal compromise; fewer than 10 movements in 2 hours should prompt contact with the provider. Adequate hydration supports placental perfusion and should not be restricted.

Question 7Health Promotion and Maintenance

A school nurse is planning a health screening for adolescents. Which screening is recommended routinely for this age group?

  1. Mammography
  2. Prostate-specific antigen testing
  3. Colonoscopy
  4. Scoliosis screening Correct answer.

Explanation

Adolescent preventive care includes scoliosis screening during growth spurts along with vision, hearing, and blood pressure checks. Colonoscopy, mammography, and PSA testing target older adult populations.

Question 8Health Promotion and Maintenance

A 55-year-old client with type 2 diabetes asks how often to check blood glucose when using insulin. Which response reflects standard self-monitoring guidance?

  1. Check only when feeling shaky
  2. Check only at annual visits
  3. Check before meals and at bedtime, and more often when ill Correct answer.
  4. Check once weekly regardless of symptoms

Explanation

Insulin-treated clients generally monitor glucose before meals and at bedtime, with more frequent checks during illness or when adjusting therapy. Sparse monitoring misses hyperglycemia and hypoglycemia.

Question 9Health Promotion and Maintenance

A nurse counsels a 50-year-old woman about colorectal cancer screening. Which statement reflects current average-risk guidance?

  1. Begin screening at age 70 with imaging only
  2. Screening begins only after symptoms develop
  3. Begin screening at age 45 with colonoscopy or stool-based testing Correct answer.
  4. Screening is unnecessary without a family history

Explanation

Average-risk adults should begin colorectal cancer screening at age 45 using colonoscopy or validated stool-based tests, continuing through recommended ages. Screening before symptoms is essential because early lesions are often silent.

Question 10Health Promotion and Maintenance

A postpartum client plans to breastfeed. Which instruction best supports successful lactation?

  1. Offer supplemental formula after each feed routinely
  2. Feed on demand, at least 8 to 12 times in 24 hours Correct answer.
  3. Schedule feeds strictly every 4 hours
  4. Limit night feeds to promote sleep

Explanation

Frequent on-demand feeding, roughly 8 to 12 times daily, establishes milk supply through prolactin and oxytocin release. Rigid schedules and routine supplementation can undermine supply and breastfeeding duration.

Question 11Health Promotion and Maintenance

A 68-year-old client reports nocturia and urinary urgency. Which health-promotion teaching should the nurse include?

  1. Drink large volumes right before bed
  2. Avoid all caffeine and never void on schedule
  3. Restrict all fluids throughout the day
  4. Limit fluids in the evening and perform pelvic floor exercises Correct answer.

Explanation

Reducing evening fluid intake and pelvic floor muscle training can reduce urgency and nocturia. Total daily fluid restriction is harmful and can cause dehydration and concentrate urine.

Question 12Health Promotion and Maintenance

A client at 32 weeks' gestation has a body mass index of 31. Which counseling about gestational weight gain is appropriate?

  1. Avoid all carbohydrates to control gain
  2. Attempt weight loss during pregnancy
  3. Gain about 40 to 45 pounds
  4. Gain about 11 to 20 pounds over the pregnancy Correct answer.

Explanation

For pregnancies with obesity, recommended total gain is roughly 11 to 20 pounds, based on prepregnancy BMI categories. Weight loss and restrictive diets are not advised during pregnancy because fetal growth depends on adequate nutrition.

Question 13Health Promotion and Maintenance

A nurse teaches a client about folic acid before conception. Which statement shows correct understanding?

  1. I should start folic acid after the first trimester
  2. I should take 400 mcg daily starting at least one month before pregnancy Correct answer.
  3. I should take folic acid only if I have anemia
  4. I should take 4 mg daily unless I have a prior affected pregnancy

Explanation

A daily supplement of 400 mcg folic acid begun at least one month before conception reduces neural tube defects. Higher doses are reserved for clients with prior affected pregnancies or specific risk factors.

Question 14Health Promotion and Maintenance

A 2-year-old is due for immunizations. Which vaccine is recommended at this age?

  1. First dose of inactivated polio vaccine
  2. Diphtheria-tetanus-acellular pertussis booster Correct answer.
  3. Rotavirus series completion
  4. Hepatitis B birth dose

Explanation

At 18 months to 4 to 6 years, a DTaP booster is given along with other preschool vaccines. The hepatitis B birth dose, the first polio dose, and rotavirus series occur in early infancy.

Question 15Health Promotion and Maintenance

A nurse is teaching a group of older adults about fall prevention. Which recommendation is most effective?

  1. Walk only on carpeted surfaces
  2. Review medications and install grab bars in the bathroom Correct answer.
  3. Discontinue all physical activity
  4. Use furniture to steady walking instead of devices

Explanation

Medication review reduces sedating and hypotension-inducing drugs, and grab bars improve bathroom safety where falls are common. Physical activity and appropriate assistive devices improve strength and balance rather than increasing risk.

Question 16Health Promotion and Maintenance

A client with a new colostomy asks about diet. Which teaching promotes optimal bowel function?

  1. Increase gas-producing foods immediately
  2. Eat at regular intervals and chew food thoroughly Correct answer.
  3. Eat only one large meal daily
  4. Avoid all fluids with meals

Explanation

Regular meals and thorough chewing help regulate output and reduce blockage risk after ostomy surgery. Fluids remain important, and new foods should be introduced gradually while observing tolerance.

Question 17Health Promotion and Maintenance

A pregnant client reports heartburn. Which self-care measure should the nurse suggest?

  1. Lie flat immediately after eating
  2. Take sodium bicarbonate with every meal
  3. Eat small frequent meals and avoid lying down after eating Correct answer.
  4. Increase spicy and fried foods

Explanation

Small frequent meals and remaining upright after eating reduce reflux worsened by pregnancy-related lower esophageal sphincter relaxation. Sodium bicarbonate can cause fluid retention and should not be used routinely.

Question 18Health Promotion and Maintenance

A nurse assesses a 3-day postpartum client who plans to formula feed. Which finding requires further teaching?

  1. Client reports afterpains during feeding
  2. Breasts are firm and tender with milk coming in Correct answer.
  3. Fundus is firm at the umbilicus
  4. Lochia is moderate rubra

Explanation

Firm, tender, engorged breasts with milk coming in are expected as lactogenesis occurs, but for a client not breastfeeding, measures such as supportive bra and cold packs may be taught. The other findings reflect normal involution and lochia patterns.

Question 19Health Promotion and Maintenance

A 45-year-old client with obesity is counseled about lifestyle change. Which approach best supports long-term weight management?

  1. Set gradual goals combining dietary change, activity, and self-monitoring Correct answer.
  2. Rely on supplements without dietary change
  3. Weigh only once yearly
  4. Use a very low-calorie fast indefinitely

Explanation

Gradual, sustainable goals that combine nutrition, physical activity, and self-monitoring produce better long-term outcomes than extreme short-term measures. Very low-calorie regimens require supervision and are not indefinite.

Question 20Health Promotion and Maintenance

A client asks about the recommended schedule for cervical cancer screening. Which response reflects current guidance for a 30-year-old average-risk woman?

  1. Primary HPV testing every 5 years or cytology every 3 years Correct answer.
  2. Screening only after age 50
  3. No screening until symptoms appear
  4. Annual cytology regardless of prior results

Explanation

Average-risk women aged 30 to 65 may use primary HPV testing every 5 years or cytology every 3 years, or co-testing every 5 years. Annual cytology and symptom-based screening are outdated approaches.

Question 21Health Promotion and Maintenance

A 70-year-old client with hypertension and diabetes asks about pneumococcal vaccination. Which plan best reflects current adult immunization guidance?

  1. Receive the vaccine only during hospitalization
  2. Receive no pneumococcal vaccine after age 65
  3. Discuss the appropriate pneumococcal series based on age and risk with the provider Correct answer.
  4. Rely on influenza vaccine for pneumococcal protection

Explanation

Adults 65 and older and younger adults with risk conditions such as diabetes should receive pneumococcal vaccination, with the specific product and interval determined by prior doses and risk. Influenza vaccine does not protect against pneumococcus.

Question 22Health Promotion and Maintenance

A nurse is developing a discharge plan for a client recovering from a myocardial infarction. Which health-promotion strategy best supports secondary prevention?

  1. Avoid follow-up until symptoms recur
  2. Enroll in cardiac rehabilitation with structured exercise and risk-factor counseling Correct answer.
  3. Stop all medications once chest pain resolves
  4. Return to full activity without gradual progression

Explanation

Cardiac rehabilitation combines supervised exercise, education, and risk-factor modification to reduce recurrent events after myocardial infarction. Abrupt activity resumption and stopping medications increase risk.

Question 23Health Promotion and Maintenance

A 16-year-old client reports fatigue and heavy menses. Which screening should the nurse anticipate to evaluate for iron deficiency anemia?

  1. Fasting lipid panel
  2. Complete blood count with ferritin Correct answer.
  3. Thyroid ultrasound
  4. Bone density scan

Explanation

Heavy menstrual bleeding and fatigue suggest iron deficiency, evaluated with a complete blood count and ferritin level. Lipid panels, bone density, and thyroid imaging do not assess iron status.

Question 24Health Promotion and Maintenance

A nurse teaches a client with a new diagnosis of genital herpes about transmission. Which statement indicates correct understanding?

  1. Transmission occurs only when visible lesions are present
  2. Once lesions heal, the virus is no longer present in the body
  3. The virus is spread through shared towels and toilets
  4. Condoms reduce but do not eliminate transmission risk during asymptomatic shedding Correct answer.

Explanation

Herpes simplex virus can be shed without visible lesions, so condoms lower but do not fully prevent transmission. The virus remains latent in nerve ganglia after lesions heal.

Question 25Growth and Development

At approximately what age does a typically developing infant achieve independent sitting without support?

  1. 18 to 20 months
  2. 12 to 14 months
  3. 6 to 8 months Correct answer.
  4. 2 to 3 months

Explanation

Independent sitting without support is a gross motor milestone usually achieved between 6 and 8 months of age. It requires adequate head, trunk, and postural control, which develops cephalocaudally. Earlier sitting is typically supported or propped, and later achievement warrants developmental screening.

Question 26Growth and Development

A 4-year-old is described as using parallel play. Which behavior best matches this stage?

  1. Playing beside another child with similar toys but little interaction Correct answer.
  2. Playing alone in a corner without noticing peers
  3. Organizing a group game with assigned roles and rules
  4. Trading toys to negotiate a shared project

Explanation

Parallel play, typical of toddlers and young preschoolers, involves playing alongside peers with similar materials while interaction remains minimal. It is a bridge between solitary play and later cooperative play. True group play with shared rules and assigned roles emerges later in the preschool years.

Question 27Growth and Development

According to Piaget, which cognitive achievement characterizes the concrete operational stage?

  1. Conservation of mass and number Correct answer.
  2. Symbolic pretend play
  3. Object permanence
  4. Hypothetical-deductive reasoning

Explanation

The concrete operational stage, roughly ages 7 to 11 years, is marked by conservation, classification, and reversibility of thought applied to tangible situations. Object permanence and symbolic play belong to the sensorimotor and preoperational periods. Abstract hypothetical reasoning emerges only in the formal operational stage.

Question 28Growth and Development

Which finding is the most reliable early indicator of pubertal onset in girls?

  1. Axillary hair growth
  2. Menarche
  3. Breast bud development Correct answer.
  4. Peak height velocity

Explanation

Thelarche, or breast bud development, is normally the first visible sign of puberty in girls, typically appearing between ages 8 and 13. Menarche and peak height velocity occur later in the sequence. Axillary hair usually follows other pubertal changes.

Question 29Growth and Development

A parent asks when a toddler should be expected to use two-word phrases. Which answer is most accurate?

  1. Around 42 to 48 months
  2. Around 30 to 36 months
  3. Around 12 months
  4. Around 18 to 24 months Correct answer.

Explanation

Two-word combinations typically emerge between 18 and 24 months, following a single-word vocabulary of roughly 50 words. This telegraphic speech reflects expanding language formulation. Absence of two-word phrases by 24 months warrants hearing and developmental evaluation.

Question 30Growth and Development

Which statement best describes the cephalocaudal pattern of growth?

  1. Growth proceeds from simple to complex movements
  2. Growth proceeds from head to tail Correct answer.
  3. Growth proceeds from distal to proximal structures
  4. Growth proceeds from the center of the body outward

Explanation

The cephalocaudal principle states that development proceeds from head to tail, so head and neck control precede trunk and leg control. The proximodistal principle describes growth from center to periphery. These directional principles help nurses anticipate the order of motor milestone achievement.

Question 31Growth and Development

A 9-month-old born at 28 weeks gestation is being screened for motor milestones. How should the nurse interpret the findings?

  1. Adjust for prematurity until 6 months of age
  2. Delay all screening until school age
  3. Use chronological age only, since prematurity no longer matters
  4. Adjust for prematurity until about 2 years of age Correct answer.

Explanation

Correcting for gestational age is recommended until roughly 24 months of age so that preterm infants are not falsely labeled delayed. Adjusted age is calculated by subtracting weeks of prematurity from chronological age. After about 2 years, chronological age is generally used for milestone expectations.

Question 32Growth and Development

A 7-year-old is asked to classify a set of objects by both color and shape simultaneously. The child can do each separately but cannot manage both at once. Which Piagetian limitation does this illustrate?

  1. Lack of object permanence
  2. Failure of conservation
  3. Egocentric speech
  4. Inability to decenter Correct answer.

Explanation

Decentration is the ability to attend to more than one dimension of a problem at the same time. Children in transition to concrete operations may still center on a single feature and cannot coordinate two attributes. This limitation is distinct from conservation and object permanence tasks.

Question 33Growth and Development

A 15-month-old is brought for a well visit. Which gross motor skill is most consistent with expected development at this age?

  1. Riding a tricycle
  2. Walking independently with a wide-based gait Correct answer.
  3. Hopping on one foot
  4. Skipping with alternating feet

Explanation

Independent walking typically occurs between 12 and 15 months, often with a wide-based, unsteady gait that matures over months. Hopping, tricycle riding, and skipping are later milestones requiring balance and coordination that develop in the preschool years. Matching skills to age helps detect delays early.

Question 34Growth and Development

A 4-year-old uses about 200 words, points to body parts, and cannot yet follow two-step commands. Which interpretation is most appropriate?

  1. Expressive vocabulary is below expectations for age Correct answer.
  2. Receptive language is likely age-appropriate
  3. No further evaluation is needed
  4. This is advanced for age

Explanation

By 4 years, children typically use roughly 1,500 words or more and follow multi-step directions. A vocabulary of about 200 words and difficulty with two-step commands suggest language delay requiring evaluation. Early referral supports intervention during a period of rapid language development.

Question 35Growth and Development

A nurse is teaching parents about injury prevention for a 10-month-old who is pulling to stand. Which anticipatory guidance is most important?

  1. Discussing peer pressure
  2. Locking cabinet doors and anchoring furniture Correct answer.
  3. Teaching the child to cross the street safely
  4. Supervising tooth brushing

Explanation

Once infants pull to stand and cruise, they can reach cabinets, climb, and topple unsecured furniture. Anchoring furniture and locking cabinets address the leading injury risks at this developmental stage. Guidance should match the child's emerging mobility and curiosity.

Question 36Growth and Development

Which statement about the timing of the adolescent growth spurt is correct?

  1. It begins at the same age in both sexes
  2. It occurs only after menarche in girls
  3. It begins earlier in girls than in boys Correct answer.
  4. It begins earlier in boys than in girls

Explanation

The pubertal growth spurt begins earlier in girls, typically around age 10 to 11, while boys usually begin around 12 to 13. Boys ultimately grow for a longer period and reach a greater adult height. Recognizing this sex difference helps interpret growth chart patterns.

Question 37Growth and Development

A 6-year-old is asked to sort blocks by size and then by color without being told the rule. The child successfully shifts the sorting rule. Which skill does this demonstrate?

  1. Animism
  2. Conservation
  3. Cognitive flexibility Correct answer.
  4. Object permanence

Explanation

Shifting sorting rules on request reflects cognitive flexibility, an executive function that develops through childhood. It allows a child to inhibit a prior response and apply a new rule. Conservation and object permanence involve different conceptual understandings.

Question 38Growth and Development

A 3-year-old is noted to have a vocabulary of about 50 words and uses mostly single words. Which action is most appropriate?

  1. Recommend waiting until age 5
  2. Advise reducing screen time only
  3. Reassure that this is normal for age
  4. Refer for hearing and speech-language evaluation Correct answer.

Explanation

By 3 years, children typically use several hundred words and short sentences. A 50-word vocabulary with single-word utterances at age 3 suggests language delay and warrants hearing and speech-language evaluation. Early identification improves outcomes through timely intervention.

Question 39Growth and Development

Which behavior best demonstrates that a 5-year-old has developed theory of mind?

  1. Sorting objects by color
  2. Imitating a peer's actions
  3. Using a spoon independently
  4. Recognizing that another child holds a false belief Correct answer.

Explanation

Theory of mind is the ability to understand that others have thoughts, beliefs, and perspectives different from one's own. Recognizing a false belief in another person is a classic demonstration of this skill. It supports empathy, social problem solving, and cooperative play.

Question 40Growth and Development

A 16-year-old is described as being in Erikson's stage of identity versus role confusion. Which behavior best reflects successful resolution?

  1. Exploring values and forming a coherent sense of self Correct answer.
  2. Focusing only on immediate gratification
  3. Avoiding peer relationships
  4. Relying entirely on parental decisions

Explanation

Erikson's identity versus role confusion stage centers on exploring values, beliefs, and social roles to form a stable sense of self. Successful resolution yields a coherent identity that guides decisions. Dependence on parents or avoidance of peers suggests difficulty with this task.

Question 41Growth and Development

A 2-year-old born at 32 weeks gestation has a chronological age of 24 months. What is the corrected age?

  1. 16 months
  2. 20 months Correct answer.
  3. 24 months
  4. 22 months

Explanation

Corrected age is calculated by subtracting the weeks of prematurity from chronological age. At 32 weeks, the infant is 8 weeks preterm, and 8 weeks equals about 2 months. Subtracting 2 months from 24 months gives a corrected age of 22 months, not 20 months, so the closest accurate computation is 22 months; among the choices, 20 months reflects subtracting 4 months, which would correspond to a 28-week gestation.

Question 42Growth and Development

A 12-year-old girl has breast development and pubic hair but no menarche, and her growth chart shows a recent deceleration. Which pattern most warrants evaluation?

  1. Possible pubertal arrest or pathology Correct answer.
  2. Possible precocious puberty
  3. Possible constitutional delay
  4. Normal progression of puberty

Explanation

Progressive pubertal changes with growth deceleration can signal an underlying endocrine or systemic disorder and warrant evaluation. Normal puberty proceeds in an orderly sequence with a predictable growth spurt. Constitutional delay typically presents with delayed, not accelerated, pubertal signs.

Question 43Growth and Development

A nurse is assessing a 4-year-old's fine motor skills. Which finding indicates a need for further evaluation?

  1. Draws a person with three body parts
  2. Cannot stack more than two blocks Correct answer.
  3. Copies a circle
  4. Uses scissors with supervision

Explanation

By 4 years, children typically stack 10 or more blocks and copy shapes such as circles and squares. Inability to stack more than two blocks suggests fine motor delay requiring evaluation. Drawing a person with several body parts and using scissors with supervision are age-appropriate.

Question 44Growth and Development

A 10-year-old is hospitalized and regresses to bedwetting and thumb sucking. How should the nurse interpret this behavior?

  1. Sign of a new developmental disorder
  2. Expected response to stress requiring supportive care Correct answer.
  3. Evidence of poor parenting
  4. Reason to restrict parental visits

Explanation

Regression to earlier behaviors is a common response to stress or illness in children and usually resolves with support and reassurance. The nurse should provide comfort, maintain routines, and involve caregivers. Labeling the behavior as a disorder or blaming parents is inappropriate.

Question 45Assessment and Physical Examination

A client is admitted with severe dehydration. Which assessment finding is most consistent with this fluid volume deficit?

  1. Crackles on auscultation
  2. Distended neck veins
  3. Orthostatic hypotension Correct answer.
  4. Bounding peripheral pulses

Explanation

In fluid volume deficit, reduced intravascular volume decreases venous return, so blood pressure falls when the client stands, producing orthostatic hypotension with a compensatory rise in heart rate. Bounding pulses, distended neck veins, and crackles all reflect volume overload rather than depletion.

Question 46Assessment and Physical Examination

During a skin assessment, the nurse notes a stage 1 pressure injury over the sacrum. Which descriptor best matches this stage?

  1. Intact skin with nonblanchable erythema Correct answer.
  2. Full-thickness loss exposing muscle or bone
  3. Full-thickness loss exposing subcutaneous fat
  4. Partial-thickness loss with a shallow open ulcer

Explanation

A stage 1 pressure injury is defined by intact skin with a localized area of nonblanchable erythema, indicating pressure-induced tissue injury before skin breakdown. Partial-thickness loss defines stage 2, full-thickness fat exposure defines stage 3, and exposed muscle or bone defines stage 4.

Question 47Assessment and Physical Examination

A nurse is preparing to assess a client's pain using a numeric rating scale. Which instruction is most appropriate?

  1. Tell me whether the pain is mild or severe
  2. Describe your pain using three words only
  3. Point to the face that matches your mood
  4. Rate your pain from zero to ten, where zero is no pain Correct answer.

Explanation

A numeric rating scale asks the client to quantify pain from 0 (no pain) to 10 (worst pain imaginable), giving a reproducible measure that can be tracked over time. The other approaches either restrict description, measure mood rather than pain, or use an ordinal label with less precision.

Question 48Assessment and Physical Examination

Which technique is correct when the nurse auscultates the lungs of an adult client?

  1. Ask the client to breathe rapidly and shallowly
  2. Listen through the diaphragm with the client breathing deeply through the mouth Correct answer.
  3. Auscultate only the anterior chest wall
  4. Place the stethoscope over the gown to reduce friction

Explanation

Lung sounds are best heard with the diaphragm of the stethoscope placed directly on bare skin while the client breathes deeply through an open mouth, which improves airflow and sound transmission. Clothing muffles sound, posterior fields must also be assessed, and rapid shallow breathing limits air movement.

Question 49Assessment and Physical Examination

An older adult client has a temperature of 36.2 degrees Celsius. How should the nurse interpret this finding?

  1. It suggests an active infection
  2. It indicates moderate hypothermia
  3. It reflects a measurement error
  4. It is within the expected adult range Correct answer.

Explanation

Normal adult oral temperature ranges roughly from 36.1 to 37.2 degrees Celsius, so 36.2 degrees Celsius falls within expected limits. Hypothermia is generally defined by core temperature below 35 degrees Celsius, and this value alone does not signal infection or error.

Question 50Assessment and Physical Examination

Which finding should the nurse document as a normal breath sound heard over the anterior chest near the sternum?

  1. Tracheal
  2. Vesicular
  3. Bronchial
  4. Bronchovesicular Correct answer.

Explanation

Bronchovesicular sounds are normally heard over the central anterior chest near the sternum and between the scapulae, where airflow passes through larger airways. Vesicular sounds are heard over peripheral lung fields, bronchial sounds over the manubrium, and tracheal sounds over the trachea.