When listening to a patients breath sounds, the nurse is unsure of a sound that is heard. The nurses next action should be to:
a. Immediately notify the patients physician.
b. Document the sound exactly as it was heard.
c. Validate the data by asking a coworker to listen to the breath sounds.
d. Assess again in 20 minutes to note whether the sound is still present.
c. Validate the data by asking a coworker to listen to the breath sounds.
When the nurse is unsure about a particular finding or assessment, the appropriate next action is to validate the data by seeking a second opinion or confirmation from another qualified healthcare professional.
In this case, where the nurse is unsure about a specific sound heard during auscultation of the patient’s breath sounds, the most appropriate action is to validate the data by asking a coworker, such as another nurse or a respiratory therapist, to listen to the breath sounds as well.
This approach serves several purposes:
The other options provided:
a. Immediately notify the patient’s physician: While informing the physician is important if an abnormal finding is confirmed, it is premature to do so without first validating the data.
b. Document the sound exactly as it was heard: Documentation is important, but validating the finding should be the first step before documenting an uncertain finding.
d. Assess again in 20 minutes to note whether the sound is still present: This option delays the validation process and may lead to missed opportunities for timely intervention if the sound is significant.
c. Validate the data by asking a coworker to listen to the breath sounds.
When unsure of a sound heard while listening to a patients breath sounds, the nurse validates the data to ensure accuracy. If the nurse has less experience in an area, then he or she asks an expert to listen.