A nurse is examining the chest of a post-operative client. Upon palpation, the nurse notes a crackling sensation. Which of the following conditions would the nurse report to the provider?
Decreased tactile fremitus.
Pleural friction fremitus.
Crepitus.
Rhonchal fremitus.
The Correct Answer is C
Choice A rationale:
Decreased tactile fremitus refers to a decreased vibration felt upon palpation of the chest, which might be indicative of conditions such as pleural effusion or pneumothorax. It is not directly associated with a crackling sensation.
Choice B rationale:
Pleural friction fremitus occurs when inflamed pleural surfaces rub against each other during breathing. It typically results in a grating sensation rather than a crackling sensation. It is associated with conditions like pleuritis.
Choice C rationale:
(Correct Choice) Crepitus refers to a crackling or grating sound/sensation that occurs when gas or air accumulates in the subcutaneous tissue. It can indicate a serious condition, such as subcutaneous emphysema, which might result from lung or chest wall injury, infections, or surgery.
Choice D rationale:
Rhonchal fremitus is associated with coarse breath sounds caused by thick secretions in the larger airways. It is felt as vibration during palpation and is not related to crackling sensations.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Providing wound irrigation might be necessary during the dressing change, but it is not the first action the nurse should take. First, the nurse should ensure they have all the necessary supplies to prevent interruptions during the procedure.
Choice B rationale:
While avoiding accidentally removing the drain is important, it is not the first action the nurse should take. Ensuring that all supplies are gathered and ready will help facilitate a smooth and organized dressing change.
Choice C rationale:
Gathering supplies is the priority in this situation. Having all the needed supplies readily available ensures that the dressing change can be carried out efficiently and without unnecessary delays.
Choice D rationale:
Providing analgesic medication as ordered by the provider is important for the patient's comfort during the procedure. However, it should not be the first action the nurse takes. First, the nurse should ensure that they have all the necessary supplies to conduct the dressing change safely.
Correct Answer is B
Explanation
Choice A rationale:
Re-measuring the respiratory rate is unnecessary. The reported respiratory rate falls within the normal range of 12-20 breaths per minute for adults.
Choice B rationale:
Re-measuring the temperature is the correct action. Tympanic temperature measurements can be influenced by factors such as earwax buildup, ear infection, or improper placement of the thermometer. Repeating the temperature measurement ensures accuracy.
Choice C rationale:
Re-measuring the pulse rate is unnecessary. The reported pulse rate of 92 beats per minute falls within the normal range of 60-100 beats per minute for adults.
Choice D rationale:
Re-measuring the blood pressure is unnecessary. The reported blood pressure of 88/58 mm Hg, while at the lower end of the normal range (typically around 90/60 mm Hg), is not excessively low and doesn't indicate an immediate need for concern.
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