Page 379 - Saunders Comprehensive Review For NCLEX-RN

When auscultating breath sounds, instruct

the client to breathe through the mouth and monitor
the client for dizziness.
10. Refer to Chapter 50 for diagnostic tests related to the
respiratory system.

11. Client teaching

a. Encourage the client to avoid exposure
to environmental hazards, including
smoking (discuss smoking cessation
programs as appropriate).
b. Client should undergo periodic
examinations as prescribed (e.g., chest
x-ray study, tuberculosis skin testing;
refer to Chapter 50.
c. Encourage the client to obtain
pneumonia and influenza
immunizations.
d. PHCP should be notified if client
experiences persistent cough, shortness
of breath, or other respiratory
symptoms.
G. Heart

1. Subjective data: Chest pain, dyspnea, cough,

fatigue, edema, nocturia, leg pain or cramps
(claudication), changes in skin color, obesity,
medications being taken, cardiovascular risk factors,
family history of cardiac or vascular problems,
personal history of cardiac or vascular problems
2. Objective data: May include inspection, palpation,
percussion, and auscultation
3. Inspection: Inspect the anterior chest for pulsations
(apical impulse) created as the left ventricle rotates
against the chest wall during systole; not always
visible.
4. Palpation
a. Palpate the apical impulse at the fourth
or fifth interspace, or medial to the
midclavicular line (not palpable in
obese clients or clients with thick chest
walls).
b. Palpate the apex, left sternal border,
and base for pulsations; normally none
are present.
5. Percussion: May be performed to outline the heart’s

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