A nurse is auscultating the breath sounds of a client who has chronic obstructive pulmonary disease.
When the client exhales, the nurse hears continuous high-pitched whistling sound.
The nurse should document this as?

Rhonchi.

Stridor.

Wheezes.

Crackles.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Rhonchi are low-pitched, coarse sounds typically heard during expiration, associated with secretions in large airways, not high-pitched continuous sounds.

Choice B rationale

Stridor is a high-pitched sound heard during inspiration, typically indicating upper airway obstruction.

Choice C rationale

Wheezes are continuous high-pitched whistling sounds heard during expiration, common in conditions like chronic obstructive pulmonary disease, where airway narrowing is present.

Choice D rationale

Crackles are discontinuous sounds heard during inspiration, usually associated with fluid in the lungs or alveolar opening, not continuous high-pitched sounds. .

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Correct Answer is C

Explanation

Choice A rationale

Glaucoma is characterized by increased intraocular pressure that can lead to optic nerve damage and peripheral vision loss. It does not typically cause central vision loss or the presence of a large black spot in the center of vision.

Choice B rationale

A detached retina often causes the sudden appearance of floaters or flashes of light, and a shadow or curtain effect in the peripheral vision. It does not typically present as a black spot in the center of vision.

Choice C rationale

Macular degeneration is an age-related condition that affects the central part of the retina (macula). It leads to central vision loss, which can manifest as a black or dark spot in the center of vision. This condition progressively impairs the ability to see fine details and perform activities like reading or recognizing faces.

Choice D rationale

Diabetic retinopathy is a complication of diabetes that affects the blood vessels in the retina. It can cause vision changes, such as floaters or blurred vision, but it does not typically present as a large black spot in the center of vision.

A. Decreased angle between the cuticles and the nails. B. Upward curving of the nails. C. Blue nails. D. Angle of nails > 160 degrees.

Correct Answer is D

Explanation

Choice A rationale

A decreased angle between the cuticles and the nails is not indicative of clubbing. In fact, it is often associated with healthy nails. Clubbing is recognized by changes that increase the angle between the nail bed and the cuticle.

Choice B rationale

An upward curving of the nails, known as koilonychia or spoon nails, is not characteristic of clubbing but is often associated with iron-deficiency anemia. Hence, this answer is incorrect for clubbing.

Choice C rationale

Blue nails indicate cyanosis, which is related to a lack of oxygen in the blood. This is distinct from clubbing, which is more about the shape and angle of the nails rather than their color.

Choice D rationale

Clubbing is recognized by an increase in the angle between the nail bed and the cuticle, often greater than 160 degrees. This is a hallmark feature and the correct indicator of clubbing.

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A nurse is auscultating the breath sounds of a client who has chronic obstructive pulmonary disease.When the client exhales, the nurse hears continuous high-pitched whistling sound.The nurse should document this as?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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A nurse is auscultating the breath sounds of a client who has chronic obstructive pulmonary disease.
When the client exhales, the nurse hears continuous high-pitched whistling sound.
The nurse should document this as?