The nurse auscultates a client's breath sounds as seen in the picture. Which type of normal sounds should the nurse hear over these lung fields?

Crackles.

Vesicular.

Bronchial.

Wheezes.

Answer and Explanation

The Correct Answer is B

A.Crackles: Crackles, also known as rales, are abnormal lung sounds that can indicate conditions such as pneumonia, pulmonary edema, or interstitial lung disease. They are often described as fine or coarse, and they may be heard during inspiration, expiration, or both. Crackles are typically heard over areas of fluid-filled alveoli or small airways.

B. Vesicular. These sounds are typically heard over most of the lung fields and are associated with normal airflow through smaller airways.

C. Bronchial: Bronchial breath sounds are typically heard over the trachea and mainstem bronchi. These sounds are louder and higher in pitch compared to vesicular sounds, with a shorter inspiratory phase and a longer expiratory phase. Hearing bronchial sounds over peripheral lung fields would suggest consolidation or compression of lung tissue, such as in pneumonia or atelectasis.

D. Wheezes: Wheezes are high-pitched, musical sounds heard primarily during expiration. They are typically associated with narrowed airways, such as in asthma, chronic obstructive pulmonary disease (COPD), or bronchitis. Wheezes may be heard over the lung fields if there is widespread airway obstruction or bronchoconstriction.

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Correct Answer is A

Explanation

A. Question the client about the frequency of falls in recent months: Falls are a common concern in older adults. Assessing the frequency of falls helps identify potential safety risks and mobility issues. It provides valuable information about the client’s functional status and balance.

B. Request to have the client lie as still as possible for the assessment: While assessing functional status, it is essential to observe the client’s mobility and ability to perform activities of daily living (ADLs). Having the client lie still would not provide relevant information about their functional abilities.

C. Assist the client with clarifying values about end-of-life care options: While discussing end-of-life care is important, it is not directly related to assessing functional status. This action is beyond the scope of a functional assessment.

D. Ask the client how often episodes of sundowning are experienced: Sundowning refers to increased confusion, agitation, or behavioural changes in older adults during the late afternoon or evening. While relevant to overall well-being, it is not specifically related to functional assessment.

A. Absolute dullness. B. Absent sounds. C. Pain. D. Musical and drum like.

Correct Answer is D

Explanation

A. Absolute dullness: This typically indicates fluid or a mass in the abdomen and is not a normal finding.

B. Absent sounds: Complete absence of bowel sounds can be a sign of an obstruction or ileus.

C. Pain: Pain during percussion suggests inflammation or irritation in the underlying organs.

D. Musical and drum like sounds: These are normal bowel sounds produced by gas and fluid movement within the intestines.

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The nurse auscultates a client's breath sounds as seen in the picture. Which type of normal sounds should the nurse hear over these lung fields?

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Naxlex Comprehensive Predictor Exams

The nurse is conducting a functional assessment on an older adult client who is reporting decreased activity due to reduced energy and strength. Which action should the nurse perform during the functional assessment?

Correct Answer is A

Explanation

The nurse completes percussion of the abdomen on an adult client. Which finding is considered normal?

Correct Answer is D

Explanation

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