NCLEX-RN
NCLEX RN Prioritization Questions Questions
Extract:
Question 1 of 5
The nurse palpates the posterior chest while the patient says 99 and notes absent fremitus. What action should the nurse take next?
Correct Answer: A
Rationale:
To assess for tactile fremitus, the nurse should use the palms of the hands to assess for vibration when the patient repeats a word or phrase such as '99'. After noting absent fremitus, the nurse should then auscultate the lungs to assess for the presence or absence of breath sounds. Absent fremitus may be noted with conditions like pneumothorax or atelectasis. The vibration is increased in conditions such as pneumonia, lung tumors, thick bronchial secretions, and pleural effusion. Encouraging the patient to turn, cough, and deep breathe is an appropriate intervention for atelectasis, but assessing breath sounds takes priority. Fremitus is decreased if the hand is farther from the lung or the lung is hyperinflated (barrel chest). Palpating the anterior chest for fremitus is less effective due to the presence of large muscles and breast tissue, making auscultation a more appropriate next step.
Question 2 of 5
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Question 3 of 5
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Question 4 of 5
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Question 5 of 5
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