A patient presents to the Emergency Room with swollen legs and shortness of breath. He tells you that he has a history of heart failure which causes the fluid to build up m his legs and lungs. When you listen to his lung sounds you are most likely to hear which type of breathing sounds?
Rales
Crackles
Rhonchi
Stridor
The Correct Answer is B
Crackles, also known as rales, are discontinuous sounds that are typically heard during inspiration in patients with heart failure. These sounds are produced by the sudden opening of small airways and alveoli that are filled with fluid or collapsed due to pulmonary congestion. The sound can be described as similar to the sound of rubbing hair between fingers or the sound of Velcro being pulled apart.
Rhonchi are continuous, low-pitched sounds that are typically heard during expiration and are caused by the movement of air through narrowed airways, such as in patients with chronic obstructive pulmonary disease (COPD). Stridor is a high-pitched, continuous sound that is typically heard during inspiration and indicates upper airway obstruction, which can be life-threatening. Neither rhonchi nor stridor are typically heard in patients with heart failure.
Therefore, based on the patient's history and symptoms, the most likely type of breathing sound to be heard on auscultation is crackles/rales.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The client's greenish-yellow sputum with a musty odor may indicate an infection, such as pneumonia or bronchitis, which can affect the client's lung function. By auscultating bilateral breath sounds, the nurse can assess for the presence of abnormal lung sounds, such as crackles or wheezing, which may indicate further respiratory compromise.
While obtaining a blood culture for tuberculosis (option b) may be appropriate in certain circumstances, the client's sputum color and odor do not necessarily indicate tuberculosis as the cause of their respiratory symptoms.
Requesting pulmonary function studies (option c) may also be beneficial in assessing the client's lung function, but this is not the priority assessment in this situation.
Finally, while documenting the findings (option d) is an important aspect of nursing care, it is not the priority action when the client is presenting with signs of compromised lung function.
Correct Answer is C
Explanation
An Incentive Spirometer is a device that helps patients take deep breaths and improve their lung function. It encourages patients to take deep breaths and to hold them for a few seconds. The device also helps to monitor and measure lung volume. By using an incentive spirometer, MA can expand her lung volume as much as possible and allow for proper oxygen blood exchange within the alveoli. This is an important technique to help prevent pneumonia and other respiratory complications.
The other options mentioned, 4L of oxygen via Nasal Cannula, Fluter Valve, and Abdominal Binder, are not appropriate devices to help MA achieve proper breathing techniques and expand lung volume. 4L of oxygen via Nasal Cannula is used to provide supplemental oxygen to patients who have difficulty breathing. Fluter Valve is a handheld device used for airway clearance in patients with chronic obstructive pulmonary disease (COPD) or cystic fibrosis. An abdominal binder is a wrap that is placed around the abdomen to support the abdominal muscles and help reduce pain after surgery or injury. These devices do not help improve lung function and are not appropriate for MA's condition.
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