While auscultating a client’s breath sounds, the nurse hears vesicular sounds in the bases of both lungs posteriorly. Which action should the nurse take in response to this finding?
A.
Continue with the remainder of the client’s physical assessment.
B.
Report the client’s abnormal lung sounds to the healthcare provider.
C.
Ask the client to cough and then auscultate at the site again.
D.
Measure the client’s oxygen saturation with a pulse oximeter.
The Correct answer and Explanation is:
Correct Answer: C. Ask the client to cough and then auscultate at the site again.
Explanation:
Vesicular breath sounds are normal sounds that are typically heard over the peripheral lung fields during inspiration and the beginning of expiration. They are characterized by a soft, low-pitched sound and are expected to be heard over most of the lung fields, particularly the posterior and lateral areas. However, hearing vesicular breath sounds specifically in the bases of both lungs posteriorly may be a normal finding, especially if the client is in a certain position or has recently been active.
Here’s a breakdown of why the appropriate response is to ask the client to cough and then auscultate again:
- Normal Variation and Positioning: Vesicular breath sounds in the bases can be a normal finding, particularly if the client is lying down or in a position that causes these sounds to be more prominent. The sound distribution can vary based on the client’s position and whether they have been lying down or sitting up.
- Detecting Changes in Breath Sounds: Coughing helps to clear the airways of any secretions or mucus that might be present. After the client coughs, auscultating the same area again can help differentiate between normal breath sounds and any abnormal sounds that might be caused by retained secretions or potential pathologies. If the breath sounds change or clear up after coughing, it could indicate that they were initially obscured by secretions.
- Avoiding Unnecessary Actions: Reporting the findings as abnormal (Option B) or measuring oxygen saturation (Option D) may not be necessary if the vesicular sounds are otherwise normal. These steps are more appropriate if other signs or symptoms suggest a problem. Continuing with the physical assessment (Option A) might miss an opportunity to clarify a potentially transient issue.
In summary, asking the client to cough and then auscultating the area again allows for a thorough assessment of the breath sounds and can help confirm whether the sounds are normal or if further investigation is needed. This approach ensures that the nurse accurately assesses the client’s lung condition and provides appropriate care based on the findings.