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.
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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Related Questions
Correct Answer is B
Explanation
A. Determining the last time the patient was suctioned:The timing of previous suctioning is not a reliable indicator of current need. Suctioning is a clinical decision based on assessment, not a fixed schedule or time interval.
B. Auscultating the breath sounds:Listening to lung sounds helps detect the presence of secretions, such as crackles or rhonchi, indicating airway obstruction. This is the most direct and effective method to assess the need for suctioning in a tracheostomized patient.
C. Monitoring the rate of respirations:An increased respiratory rate can suggest respiratory distress but is non-specific and may result from various causes, including anxiety, fever, or pain. It does not definitively indicate the presence of secretions.
D. Examining the character of the sputum:Sputum characteristics provide information about infection or hydration status, but unless secretions are visibly present or obstructing the airway, they don’t confirm the immediate need for suctioning.
Correct Answer is D
Explanation
A. When the chest x-ray shows no indication of TB:Chest x-rays can remain abnormal even after successful treatment. Radiographic improvement is not a reliable indicator for stopping therapy.
B. When the TB skin test is no longer positive:The TB skin test often remains positive for life after infection or exposure and does not reflect current disease activity or treatment response.
C. When the medication has been taken for 6 months:Although the standard treatment duration is often 6 months, therapy duration alone is not sufficient without confirming bacteriological clearance via sputum testing.
D. When three consecutive sputum cultures are negative:This is the most reliable indicator that the patient is no longer infectious and the treatment has been effective, especially in active pulmonary TB. It ensures eradication of Mycobacterium tuberculosis.
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