Question

When performing physical assessment, the nurse auscultates adventitious breath sounds. How should the nurse document this?

1) As a normal finding
2) As an abnormal finding
3) As a sign of respiratory distress
4) As a sign of cardiovascular disease

Answer 1

Adventitious breath sounds auscultated by a nurse should be documented as an abnormal finding, as they can indicate potential respiratory conditions such as pneumonia. Proper documentation following auscultation is essential for accurate diagnosis and treatment.

Step-by-step explanation:

When performing a physical assessment, if the nurse auscultates adventitious breath sounds, which often include crackles, wheezes, or rhonchi, these should be documented as an abnormal finding. Adventitious sounds are indicative of a possible respiratory pathology and are not considered normal. An accurate documentation of these findings is crucial for diagnosis and subsequent treatment.

For instance, in clinical scenarios in which a patient like Barbara presents with crackling breath sounds and a chest radiograph reveals a "shadow" in the lung, these would suggest the presence of a condition such as pneumonia. In Marsha’s case, the crepitation heard in her lungs led to further evaluation and appropriate medical intervention. Auscultation is a key diagnostic procedure not only for assessing the respiratory system but also for evaluating heart sounds which may reveal murmurs indicative of cardiovascular anomalies.