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    HESI RN Health Assessment Proctored Exam

    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?

    Explanation & Rationale

    Choice A rationale Vesicular breath sounds are normal breath sounds heard over the peripheral lung fields. Hearing vesicular sounds in the bases of both lungs posteriorly indicates normal air movement in the lungs. Therefore, the nurse should continue with the remainder of the client’s physical assessment. Choice B rationale Reporting the client’s lung sounds to the healthcare provider is unnecessary because vesicular breath sounds are normal and do not indicate any abnormality. Choice C rationale Asking the client to cough and then auscultate at the site again is not required since vesicular breath sounds are normal and do not indicate any need for further immediate assessment. Choice D rationale Measuring the client’s oxygen saturation with a pulse oximeter is not necessary in this context because the vesicular breath sounds indicate normal lung function.

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