A nurse is providing care after auscultating clients' breath sounds. Which assessment finding is correctly matched to the nurse's primary intervention?

Crackles are heard in bases. - The nurse encourages the client to cough forcefully.

Wheezes are heard in central areas. - The nurse administers an inhaled bronchodilator.

Vesicular sounds are heard over the periphery. - The nurse has the client breathe

Hollow sounds are heard over the trachea. - The nurse increases the oxygen flow rate.

Answer and Explanation

The Correct Answer is B

A. Crackles are heard in bases. – The nurse encourages the client to cough forcefully:
Crackles are caused by fluid in the alveoli and are often not cleared with coughing. Encouraging coughing may help with mucus, but for fluid-related crackles (e.g., in heart failure), diuretics or other interventions are more appropriate.

B. Wheezes are heard in central areas. – The nurse administers an inhaled bronchodilator: Wheezes result from narrowed airways, commonly seen in asthma or bronchospasm. Bronchodilators relax airway smooth muscle, improving airflow and reducing wheezing.

C. Vesicular sounds are heard over the periphery. – The nurse has the client breathe:
Vesicular breath sounds are normal over the peripheral lung fields. No action is needed when these sounds are heard, so prompting the client to breathe differently is unnecessary.

D. Hollow sounds are heard over the trachea. – The nurse increases the oxygen flow rate: Hollow, tubular sounds (bronchial) are expected over the trachea. These are normal findings and not an indication of hypoxia. Increasing oxygen unnecessarily could be harmful.

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Correct Answer is A

Explanation

A. A possible airway obstruction: The tripod positionis a classic sign of epiglottitis and indicates the child is attempting to maximize airway patency. This posture helps keep the airway open and suggests significant upper airway obstruction, requiring immediate intervention.

B. The presence of pain: While children with epiglottitis often experience throat pain, this posture is not primarily used to relieve pain. It is associated with efforts to ease breathing and maintain airflow in the face of an obstructed or narrowed airway.

C. Extreme fatigue: Fatigue may occur in respiratory illnesses, but the tripod position is an active posture that requires muscle engagement. It is not a typical sign of fatigue and more accurately reflects respiratory distress and airway compromise.

D. Dehydration: Dehydration may be present in epiglottitis due to poor oral intake, but it does not cause the child to assume the tripod position. The posture is a compensatory mechanism for airway obstruction, not a direct result of fluid imbalance.

A. drink juices high in vitamin C B. cough into your elbow C. wash hands frequently D. cover the mouth and nose with when sneezing E. use a saline nose spray frequently

Correct Answer is ["B","C","D"]

Explanation

A. Drink juices high in vitamin C: While vitamin C may help support immune function, it does not prevent the transmission of colds to others. This measure is more about personal health and has no direct effect on reducing contagion.

B. Cough into your elbow: Coughing into the elbow instead of the hands prevents the spread of respiratory droplets through touch, reducing the likelihood of contaminating surfaces and infecting others.

C. Wash hands frequently: Hand hygiene is one of the most effective ways to prevent the spread of respiratory viruses. Frequent handwashing helps remove viruses acquired from contaminated surfaces or respiratory secretions.

D. Cover the mouth and nose when sneezing: Covering the mouth and nose with a tissue or elbow during sneezing limits the dispersion of infectious droplets into the air, reducing transmission to others.

E. Use a saline nose spray frequently: Saline sprays may keep nasal passages moist and comfortable, but they do not reduce the risk of spreading infection to others. Their use is symptomatic, not preventive from a contagion standpoint.

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A nurse is providing care after auscultating clients' breath sounds. Which assessment finding is correctly matched to the nurse's primary intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse employed in an emergency department is monitoring a child diagnosed with epiglottitis. The nurse notes that the child is leaning forward with the chin thrust out. How should the nurse interpret this finding?

Correct Answer is A

Explanation

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Correct Answer is ["B","C","D"]

Explanation

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