After auscultating which adventitious breath sound should the nurse have the patient cough and then auscultate again?

Rhonchi.

Wheeze.

Crackles.

Stridor.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Rhonchi are low-pitched, continuous breath sounds that are often indicative of secretions in the large airways. These sounds may change or clear with coughing, so the nurse should have the patient cough and then auscultate again to reassess the presence of rhonchi.

Choice B rationale

Wheezes are high-pitched, musical sounds heard primarily during expiration. They are caused by narrowed airways, typically due to asthma or other obstructive lung conditions. Wheezes do not usually clear with coughing and require specific treatments to address airway constriction.

Choice C rationale

Crackles are discontinuous, popping sounds heard during inspiration and are associated with fluid in the alveoli, such as in conditions like pneumonia or heart failure. Crackles are not typically cleared by coughing and may persist despite the patient's efforts to clear their airways.

Choice D rationale

Stridor is a high-pitched, harsh sound heard during inspiration, often indicating upper airway obstruction. Stridor is a medical emergency and requires immediate intervention to secure the airway. It does not clear with coughing and signifies a critical respiratory issue. .

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Correct Answer is D

Explanation

Choice A rationale

Visual acuity tests assess the clarity of vision and the ability to discern letters or numbers at a set distance. It is used to test the function of cranial nerve II (optic nerve) rather than cranial nerve III (oculomotor nerve). Testing visual acuity involves using eye charts and assessing each eye separately.

Choice B rationale

Peripheral vision tests evaluate the ability to see objects outside the direct line of vision and are used to test the function of cranial nerve II (optic nerve). Peripheral vision assessment helps in diagnosing conditions like glaucoma but does not test the function of cranial nerve III.

Choice C rationale

The presence of the red reflex is assessed by looking into the eye with an ophthalmoscope to check for abnormalities in the eye's posterior segment. It is not related to the function of cranial nerve III but rather indicates healthy eye structures, including the retina and optic nerve (cranial nerve II).

Choice D rationale

Pupillary constriction to light is a direct test of cranial nerve III function. The oculomotor nerve controls the constriction of the pupil in response to light. By shining a light into the eyes and observing the pupils' response, the nurse can assess the integrity of cranial nerve III.

A. Rhonchi. B. Stridor. C. Wheezes. D. Crackles.

Correct Answer is C

Explanation

Choice A rationale

Rhonchi are low-pitched, coarse sounds typically heard during expiration, associated with secretions in large airways, not high-pitched continuous sounds.

Choice B rationale

Stridor is a high-pitched sound heard during inspiration, typically indicating upper airway obstruction.

Choice C rationale

Wheezes are continuous high-pitched whistling sounds heard during expiration, common in conditions like chronic obstructive pulmonary disease, where airway narrowing is present.

Choice D rationale

Crackles are discontinuous sounds heard during inspiration, usually associated with fluid in the lungs or alveolar opening, not continuous high-pitched sounds. .

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After auscultating which adventitious breath sound should the nurse have the patient cough and then auscultate again?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When inspecting a patient's eyes, the nurse assesses the presence of cranial nerve III (oculomotor nerve) by observing the eyelids open and close bilaterally.What other technique does a nurse use to test the function of this cranial nerve?

Correct Answer is D

Explanation

A nurse is auscultating the breath sounds of a client who has chronic obstructive pulmonary disease.When the client exhales, the nurse hears continuous high-pitched whistling sound.The nurse should document this as?

Correct Answer is C

Explanation

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