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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "I have cared for patients who were able to have the tracheostomy reversed. While this may offer hope, it shifts the focus to long-term outcomes rather than addressing the patient's current emotional state. Not all tracheostomies are reversible, and offering this reassurance prematurely may set unrealistic expectations.
B. “I understand that you might be apprehensive." This statement acknowledges the patient's anxiety and fosters trust. Demonstrating empathy helps reduce emotional distress, encourages open communication, and supports emotional adaptation to the tracheostomy.
C. “I will be efficient and give care quickly." Although efficiency is important, this response may come off as dismissive of the patient's emotional needs. It prioritizes task completion over patient-centered care and fails to address the underlying anxiety.
D. "I will wait until your tracheostomy heals before teaching." Teaching should begin early, even in small steps, to help the patient gradually understand and adapt to tracheostomy care. Delaying education may increase fear, uncertainty, and dependence on others for care.
Correct Answer is D
Explanation
A. Physical therapy for homebound therapy services:Physical therapy is not routinely indicated in TB management unless the patient has specific mobility deficits. TB treatment focuses more on medication adherence and infection control rather than physical rehabilitation.
B. Occupational therapy for job retraining:There is no direct indication for job retraining in a TB patient unless the illness has caused long-term disability or affected occupational function, which is not suggested in this scenario.
C. Community social worker for Meals on Wheels:Meals on Wheels may assist with nutrition, but it is not specific to TB care. Social services do not directly ensure adherence to TB therapy, which is crucial for treatment success and public health safety.
D. Visiting Nurses for directly observed therapy:Directly observed therapy (DOT) ensures the client takes prescribed TB medications under supervision, which is essential to prevent noncompliance, reduce drug resistance, and promote cure. Visiting nurses are best positioned to provide this support during long-term outpatient TB treatment.
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