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 ["A","C","D","E"]
Explanation
Choice A rationale:
Dyspnea is a common finding in clients with emphysema. Emphysema is a chronic obstructive pulmonary disease (COPD) characterized by the destruction of the alveoli in the lungs, leading to difficulty breathing and shortness of breath. The loss of alveoli reduces the surface area for gas exchange, causing dyspnea.
Choice B rationale:
Bradycardia is not typically associated with emphysema. In fact, it is more common for clients with emphysema to have an increased heart rate (tachycardia) due to the body's compensatory response to low oxygen levels in the blood.
Choice C rationale:
Clubbing of the fingers is often seen in clients with chronic respiratory conditions like emphysema. It is a result of chronic hypoxia and is characterized by the abnormal rounding and thickening of the fingertips and nail beds.
Choice D rationale:
Barrel chest is a common physical finding in clients with emphysema. It is characterized by an increase in the anteroposterior diameter of the chest due to overinflation of the lungs. This change in chest shape is a result of chronic air trapping and hyperinflation, which are hallmarks of emphysema.
Choice E rationale:
Shallow respirations are expected in clients with emphysema. Due to the loss of alveolar elasticity and increased airway resistance, clients with emphysema tend to take shallow breaths, which are less effective for oxygen exchange.
Correct Answer is C
Explanation
The correct answer is choice C. Monitor the client for black, tarry stools.
Choice A rationale:
Administering clopidogrel with each meal is not necessary. Clopidogrel can be taken with or without food. The primary concern with clopidogrel is its potential to cause bleeding, so monitoring for signs of bleeding is more critical.
Choice B rationale:
Having suction equipment at the bedside is not specifically required for clients taking clopidogrel. This action is more relevant for clients at risk of airway obstruction or those undergoing procedures that might require suctioning.
Choice C rationale:
Monitoring the client for black, tarry stools is essential because it can indicate gastrointestinal bleeding, a known side effect of clopidogrel. This medication increases the risk of bleeding, so observing for signs of internal bleeding, such as melena (black, tarry stools), is crucial.
Choice D rationale:
Initiating contact precautions is not necessary for clients taking clopidogrel. Contact precautions are typically used to prevent the spread of infections, not for managing clients on antiplatelet therapy.
By understanding these rationales, the nurse can ensure the safe administration and monitoring of clopidogrel therapy.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.