A nurse is auscultating the breath sounds of a client who has asthma. When the client exhales, the nurse hears continuous high-pitched squeaking sounds. The nurse should document this as which adventitious breath sounds?

Wheezes

Crackles

Rhonchi

Stridor

Answer and Explanation

The Correct Answer is A

A. Wheezes are continuous high-pitched sounds that occur during expiration (or sometimes inspiration) and are common in conditions like asthma due to narrowed airways.

B. Crackles are discontinuous sounds often described as popping or crackling and are not typically high-pitched.

C. Rhonchi are low-pitched, snoring-like sounds caused by the obstruction of larger airways and are not characterized as high-pitched.

D. Stridor is a high-pitched sound usually associated with upper airway obstruction and is not typically heard with asthma.

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Correct Answer is C

Explanation

A. Restlessness is an objective sign that may indicate pain, but it is not a subjective report from the client.

B. Pupil dilation is an objective physiological response often associated with pain or stress, not a subjective indicator.

C. A report of a burning sensation is a subjective indicator because it is based on the client’s own description of their pain experience.

D. Grimacing is an objective observation by the nurse, not a subjective report from the client.

A. Flexion B. Supination C. Rotation D. Pronation

Correct Answer is D

Explanation

A. Flexion refers to bending the joint, which does not apply when turning the palm down.

B. Supination is the movement of turning the palm up, which is the opposite of what is being tested here.

C. Rotation refers to the circular movement around a central point, but it does not specifically describe the action of turning the palm down.

D. Pronation is the movement of turning the palm down, which is exactly what the client is doing when asked to perform this maneuver.

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A nurse is auscultating the breath sounds of a client who has asthma. When the client exhales, the nurse hears continuous high-pitched squeaking sounds. The nurse should document this as which adventitious breath sounds?

Nursing Test Bank

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Correct Answer is C

Explanation

When assessing the elbow, a nurse asks a client to hold the arm out and turn the palm down. When the client performs this maneuver, the nurse is testing what?

Correct Answer is D

Explanation

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