A nurse is auscultating the breath sounds of a client who has congestive heart failure. When the client exhales, the nurse hears bubbling, popping like sounds. The nurse should document this as which of the following adventitious breath sounds?
Wheezes
Stridor
Rhonchi
Crackles
The Correct Answer is D
A. Wheezes:
Wheezes are high-pitched, musical sounds that occur during inspiration or expiration and are often associated with narrowed airways, such as in conditions like asthma or chronic obstructive pulmonary disease (COPD).
B. Stridor:
Stridor is a high-pitched, crowing sound that is typically heard during inspiration and can be associated with upper airway obstruction, such as in croup or epiglottitis.
C. Rhonchi:
Rhonchi are low-pitched, snoring or rattling sounds that can occur during inspiration or expiration. They are often associated with the presence of mucus or other airway obstruction and can be heard in conditions like bronchitis or pneumonia.
D. Crackles:
Crackles are bubbling, popping sounds heard during inspiration or expiration. They can be further classified as fine or coarse. Fine crackles are often associated with conditions like pulmonary fibrosis, while coarse crackles can be heard in conditions like congestive heart failure or pneumonia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Place the client on bed rest in supine position:
While bed rest might be appropriate for certain respiratory conditions, it is not a specific intervention for crackles. In fact, changing the client's position, such as having them sit up, may enhance lung function and help with breathing.
B. Repeat auscultation after asking the client to breathe deeply and cough:
This is the correct action. Repeating auscultation after having the client take deep breaths and cough can provide additional information about the nature of the crackles and may help clear the airways temporarily.
C. Prepare to administer antibiotics:
Administering antibiotics would be considered if the crackles are indicative of a respiratory infection. However, determining the need for antibiotics would require a more comprehensive assessment, including diagnostic tests.
D. Instruct the client to limit fluid intake to less than 2,000 mL/day:
Limiting fluid intake is not a direct intervention for crackles. This action is typically considered in conditions like heart failure where there is a risk of fluid overload. It is not the primary intervention for addressing crackles in the lungs.
Correct Answer is C
Explanation
A. Comatose:
Coma refers to a state of deep unconsciousness where the individual is unresponsive to stimuli, including pain or external stimulation. In the scenario described, the patient is not comatose because they can be awakened by gentle shaking and calling their name.
B. Awake and alert:
This term describes a state of full alertness and responsiveness to the environment. The patient in the scenario is not fully awake and alert since they appear drowsy most of the time and require external stimuli to be awakened.
C. Lethargic:
Lethargy is characterized by drowsiness, reduced alertness, and a sluggish response to stimuli. In the scenario, the patient is described as drowsy most of the time but can be awakened by gentle shaking and calling their name. This aligns with the characteristics of lethargy.
D. Stuporous:
Stupor is a state of reduced responsiveness where the individual can be aroused only by vigorous or painful stimuli. The patient in the scenario does not fit the criteria for stupor as they can be awakened by gentle shaking and calling their name.
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