A nurse is collecting data from a client who is having an acute asthma exacerbation.
When auscultating the client's chest, the nurse should expect to hear which of the following sounds?
Fine rales.
Rhonchi.
Expiratory wheeze.
Pleural friction rub.
The Correct Answer is C
Choice A rationale:
Fine rales Fine rales, also known as crackles, are typically associated with conditions like pulmonary edema, pneumonia, or interstitial lung diseases. These sounds are often described as "crackling" or "popping" and are heard during inspiration. In an acute asthma exacerbation, expiratory wheezing is more characteristic than fine rales.
Choice B rationale:
Rhonchi Rhonchi are continuous, low-pitched sounds that can be heard in conditions like chronic obstructive pulmonary disease (COPD) or bronchitis. They are typically present during both inspiration and expiration. In an acute asthma exacerbation, you would expect to hear wheezing during expiration, which is different from the characteristics of rhonchi.
Choice D rationale:
Pleural friction rub Pleural friction rub is a grating, leathery sound caused by the inflamed pleura rubbing against each other. It is typically heard during both inspiration and expiration and is associated with conditions like pleuritis or pleurisy. It is not commonly associated with acute asthma exacerbation. Now, let's move on to the next question.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
"Pitting edema of the lower legs.”. Pitting edema is a common sign of congestive heart failure (CHF), and it often occurs bilaterally in the lower extremities. While this is a potential finding in left-sided heart failure, it is not specific to it.
Choice B rationale:
"Jugular venous distention.”. Jugular venous distention (JVD) is more indicative of right-sided heart failure or elevated central venous pressure. It is not a typical finding in left-sided heart failure.
Choice C rationale:
"Shortness of breath while lying down.”. This is a classic symptom of left-sided heart failure, known as orthopnea. When the patient lies flat, fluid that has accumulated in the lungs can lead to difficulty breathing. Patients with left-sided heart failure often find relief by sleeping with their upper body elevated.
Choice D rationale:
"Right upper quadrant pain.”. Right upper quadrant pain is not a typical finding in left-sided heart failure. It may be associated with issues related to the liver or gallbladder but is not directly related to heart failure.
Correct Answer is B
Explanation
Choice A rationale:
Extreme thirst is not a typical finding in a client with hypokalemia. Hypokalemia is an electrolyte imbalance that can lead to symptoms like weakness and irregular heartbeats, but extreme thirst is not a direct result of low potassium levels.
Choice B rationale:
"Weak, irregular pulse" is the correct response. Hypokalemia can lead to cardiac arrhythmias, which may manifest as a weak, irregular pulse. Potassium plays a crucial role in maintaining the electrical activity of the heart, and low levels can disrupt normal heart rhythms.
Choice C rationale:
Hyperactive bowel sounds are not typically associated with hypokalemia. Instead, you might expect diminished or absent bowel sounds in severe cases due to muscle weakness.
Choice D rationale:
Hyperactive reflexes are not typically associated with hypokalemia. Instead, hypokalemia can lead to muscle weakness and potentially even paralysis in severe cases.
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