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 ["B"]
Explanation
Place the call bell in reach and respond promptly when activated.
This is a safety measure that allows the client to communicate their needs and request assistance when needed. The nurse should also check the drain for patency, observe for bright red bloody drainage, and maintain an aseptic technique when emptying the drain.
Choice A is wrong because advising the client to stay in bed and only get up with assistance may limit their mobility and increase the risk of complications such as deep vein thrombosis, pulmonary embolism, or pneumonia.
The client should be encouraged to ambulate as soon as possible after surgery, with appropriate assistance and precautions.
Choice C is wrong because maintaining the bed at working height for convenience when doing post-op vital signs may increase the risk of falls or injury if the client tries to get out of bed without assistance.
The bed should be lowered to a safe position and locked when not in use.
Choice D is wrong because keeping the lights off to encourage the client to rest and recuperate may impair the client’s vision and orientation, and increase the risk of falls or injury if they try to get out of bed without assistance.
The client should have adequate lighting in their room and be oriented to their surroundings.
Choice E is wrong because attaching the drain to wall suction and keeping the tubing pinned to the client’s gown may interfere with the function of the drain and cause tension or kinking of the tubing. The drain should be attached to gravity drainage and secured loosely to prevent accidental dislodgment.
Correct Answer is D
Explanation
30 to 40 mL/hour. This is the normal range of urine output for a typical adult client. The urine output should be at least 0.5 mL/kg/hour for adults.
Assuming an average weight of 70 kg, this would be 35 mL/hour.
Choice A is wrong because 5 to 10 mL/hour is too low and indicates oliguria, which is a sign of inadequate kidney function or dehydration.
Choice B is wrong because 12 to 15 mL/hour is also below the normal range and may indicate oliguria.
Choice C is wrong because 16 to 25 mL/hour is slightly below the normal range and may indicate reduced kidney perfusion or fluid intake.
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