A nurse is documenting the findings of a physical examination on a client who has heart failure.

Which of the following terms should the nurse use to describe crackles heard in the lungs?

Rales

Rationale: Rales are fine, high-pitched crackling sounds heard in the lungs due to fluid accumulation or inflammation. They are commonly heard in clients who have heart failure, pneumonia, or pulmonary edema.

Incorrect options:

A) Wheezes - Wheezes are high-pitched musical sounds heard in the lungs due to narrowed airways. They are commonly heard in clients who have asthma, chronic obstructive pulmonary disease (COPD), or bronchitis.

B) Rhonchi - Rhonchi are low-pitched snoring sounds heard in the lungs due to secretions or mucus in the large airways. They are commonly heard in clients who have bronchitis, cystic fibrosis, or pneumonia.

D) Stridor - Stridor is a high-pitched crowing sound heard in the upper airway due to obstruction or inflammation. It is commonly heard in clients who have croup, epiglottitis, or foreign body aspiration.

All of the above

Rationale: The nurse should apply suction for no longer than 10 seconds at a time, preoxygenate the client with 100% oxygen before suctioning, and limit the number of suction passes to three per session to prevent hypoxia during tracheostomy suctioning. These actions help to minimize the interruption of oxygen delivery and reduce the risk of mucosal trauma and bleeding.

Incorrect options:

None