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 C

Explanation

Choice A rationale

Leukoplakia refers to white patches or plaques that develop on the mucous membranes of the oral cavity. It is usually seen as a precancerous condition and is associated with chronic irritation, smoking, or other risk factors. These white patches are not typically associated with redness and bleeding of the gums.

Choice B rationale

Gingival hyperplasia involves the overgrowth or enlargement of the gums. It can be due to various factors, including medications (such as anticonvulsants or calcium channel blockers), hormonal changes, or certain systemic conditions. While the gums may appear enlarged and possibly bleed, gingival hyperplasia is not characterized by redness and bleeding as primary symptoms.

Choice C rationale

Gingivitis is the inflammation of the gums (gingiva) and is characterized by redness, swelling, and bleeding. It is usually caused by plaque buildup along the gumline, leading to irritation and inflammation. Gingivitis is considered an early stage of gum disease and can be reversed with proper oral hygiene and dental care.

Choice D rationale

Periodontitis is an advanced stage of gum disease that occurs when gingivitis is left untreated. It involves the destruction of the supporting structures of the teeth, including the alveolar bone and periodontal ligaments. Symptoms of periodontitis include gum recession, pockets forming between the gums and teeth, and possible tooth loss. While periodontitis can lead to bleeding gums, it is more severe than the initial symptoms of redness and bleeding seen in gingivitis.

A. Patches of eschar cover parts of the wound. B. Partial thickness skin erosion is observed with a loss of dermis and epidermis. C. Ulcer extends into the subcutaneous tissue. D. Intact skin appears red but not broken. E. Open blister areas have a red-pink wound bed. F. Localized redness in light skin will blanch with fingertip pressure.

Correct Answer is ["B","E"]

Explanation

Choice A rationale

Patches of eschar covering parts of the wound are characteristic of more advanced pressure ulcers, such as Stage III or IV, where necrotic tissue is present. Eschar is a dark, thick, leathery scab or crust that indicates deeper tissue damage and is not observed in Stage II pressure ulcers.

Choice B rationale

A Stage II pressure ulcer is characterized by partial thickness skin erosion with loss of the epidermis and dermis. It appears as a shallow open ulcer with a red-pink wound bed, indicating that the damage has not extended beyond these layers of skin.

Choice C rationale

When a pressure ulcer extends into the subcutaneous tissue, it is classified as a Stage III or IV ulcer, depending on the depth and extent of tissue involvement. Stage II ulcers are limited to the epidermis and dermis and do not reach the subcutaneous layer.

Choice D rationale

Intact skin that appears red but is not broken is indicative of a Stage I pressure ulcer, which represents the earliest stage of pressure injury. Stage I ulcers involve non-blanchable erythema (redness) but no open wound or skin erosion.

Choice E rationale

Open blister areas with a red-pink wound bed are characteristic of Stage II pressure ulcers. These ulcers exhibit partial thickness skin loss and can present as open or fluid-filled blisters with a visible wound bed.

Choice F rationale

Localized redness in light skin that blanches with fingertip pressure is typical of a Stage I pressure ulcer. Blanching erythema indicates that the skin is still viable and blood flow is present, which differentiates Stage I from more advanced stages of pressure injury.

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

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Naxlex Comprehensive Predictor Exams

The nurse is inspecting the gums on a patient and notices redness and bleeding.Which unexpected finding is present?

Correct Answer is C

Explanation

A patient has been admitted to the hospital after the staff at a nursing home noticed a pressure ulcer on his sacral area.The nurse examines the sacral ulcer and determines it is a Stage II ulcer.Which of these findings is characteristic of a Stage II pressure ulcer?

Correct Answer is ["B","E"]

Explanation

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