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    Med Surg Proctored ExamQuestion 21
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    Med Surg Proctored Exam

    The nurse is performing the technique shown below. What is the nurse assessing?

    Explanation & Rationale

    The technique shown involves the nurse placing both hands on the client’s posterior or anterior chest wall with the thumbs pointing toward the spine or midline, creating a small fold of skin between the thumbs. As the client takes a deep breath, the nurse observes the movement of their hands. Rationale: A. Lung Consolidation: Consolidation, where lung tissue becomes firm/solid due to fluid or pus, often in pneumonia, is primarily assessed through percussion (producing a "dull" sound) or auscultation (hearing bronchial breath sounds where they shouldn't be). B. Chest Expansion: The primary goal of this maneuver is to assess the symmetry and depth of thoracic excursion. When the client inhales deeply, the nurse’s thumbs should move apart symmetrically. If one thumb moves less than the other, it indicates asymmetrical chest expansion. This can be a sign of underlying localized pathologies such as pneumothorax, pleural effusion, pneumonia, or fractured ribs. C. Tactile Fremitus: To assess tactile fremitus, the nurse uses the palmar base of the hands or the ulnar surface of the hand while the client repeats a resonant phrase like "ninety-nine" or "one-one-one." Tactile fremitus measures vibrations transmitted through the bronchopulmonary system to the chest wall. It does not focus on the physical distance the thumbs travel during a breath.

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