A nurse assessing a client’s lung sounds hears continuous low-pitched harsh rattling sounds over the client’s trachea that are most evident on expiration and are decreased after coughing.
Which term is the appropriate choice to accurately document this lung sound?
Rhonchi.
Wheezing.
Crackles.
Pleural friction rub.
The Correct Answer is A
Rhonchi. Rhonchi are low-pitched, rattling sounds that indicate mucus in the larger airways. They are most evident on expiration and may decrease after coughing.
Choice B is wrong because wheezes are high-pitched, squeaking sounds that indicate narrowed small air passages. They are usually heard on both inspiration and expiration.
Choice C is wrong because crackles are short, high-pitched popping sounds that indicate fluid or inflammation in the alveoli. They are usually heard on inspiration.
Choice D is wrong because pleural friction rubs are creaking or grating sounds that indicate inflammation of the pleura. They are usually heard on both inspiration and expiration and do not change with coughing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
On a regular schedule around the clock. This is because when pain is present for more than 12 hours a day, analgesic dosages are best administered around the clock rather than on an as-needed basis.
Choice A is wrong because waiting for the client to exhibit physiologic symptoms of pain may delay the administration of analgesics and cause unnecessary suffering. Physiologic symptoms of pain are not always reliable indicators of pain intensity or quality.
Choice B is wrong because administering analgesics prior to painful activities may not provide adequate pain relief throughout the day. Painful activities may vary depending on the client’s condition and preferences.
Choice D is wrong because relying on the client’s request may not ensure optimal pain management. Some clients may be reluctant to ask for analgesics due to fear of addiction, side effects, or being perceived as weak.
Correct Answer is C
Explanation
This is because responding inappropriately to questions can indicate that the client has difficulty hearing or understanding what is being asked. According to, hearing loss makes communication with the outside world difficult, and can result in new or exaggerated symptoms that are mistakenly attributed to cognitive decline.
Choice A is wrong because speaking in a low voice does not necessarily imply hearing loss. It could be due to other factors such as shyness, anxiety, or vocal cord problems.
Choice B is wrong because refusing to answer questions does not necessarily imply hearing loss.
It could be due to other factors such as lack of interest, defiance, or distrust.
Choice D is wrong because looking away from persons while speaking does not necessarily imply hearing loss.
It could be due to other factors such as cultural norms, eye contact avoidance, or distraction.
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