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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

This is because immobilizing the wrist prevents kinking or dislodgement of the intravenous catheter and reduces the risk of complications such as infiltration, phlebitis, or infection.

Some additional information for the response are:

Choice A is wrong because placing the arm across the client’s chest may compromise venous return and increase the risk of thrombosis.

Choice B is wrong because using a wrist restraint may cause skin breakdown, nerve damage, or impaired circulation.

Choice D is wrong because instructing the client to limit use the of that arm may not be sufficient to prevent catheter movement or accidental removal.

Normal ranges for venous access depend on the type and location of the catheter, but some general values are: potassium (3 to 5 mEq/L), blood urea nitrogen (10 to 20 mg/dL), and central venous pressure (8 to 12 mmHg).

A. Metoprolol. B. Hydrochlorothiazide. C. Enoxaparin. D. Atorvastatin.

Correct Answer is B

Explanation

The nurse should hold and notify the prescriber because hydrochlorothiazide is a diuretic that can lower the serum potassium level. The client already has a high serum potassium level of 5.2 mmol/L, which is above the normal range of 3.5 to 5.0 mmol/L.

Giving hydrochlorothiazide could worsen the client’s condition and cause hypokalemia.

Choice A is wrong because metoprolol is a beta-blocker that can lower the blood pressure and heart rate.

The client’s blood pressure and heart rate are not given, so there is no reason to hold metoprolol based on the information provided.

Choice C is wrong because enoxaparin is an anticoagulant that can prevent blood clots. The client has a low platelet count of 98,000/mm, which is below the normal range of 150,000 to 450,000/mm.

However, this does not contraindicate the use of enoxaparin, unless the client has signs of bleeding or bruising.

Choice D is wrong because atorvastatin is a statin that can lower the serum cholesterol

level. The client has a high serum cholesterol level of 250 mg/dL, which is above the desirable level of less than 200 mg/dL.

Giving atorvastatin could help reduce the client’s risk of cardiovascular complications.

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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?

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Naxlex Comprehensive Predictor Exams

A client with difficult venous access has an intravenous insertion site located at the bend of the wrist. Which action would be most appropriate for a nurse to take?

Correct Answer is C

Explanation

Correct Answer is B

Explanation

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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?