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 C

Explanation

A: Apply a pulse oximeter to the foot. Continuous monitoring of oxygen saturation can help detect hypoxemia early, which can be a concern in post-term infants due to potential respiratory distress or meconium aspiration. However, while important, this is a monitoring measure and not an immediate corrective action for potential metabolic or respiratory issues directly associated with post-term birth.

B: Draw arterial blood gases. Arterial blood gases (ABGs) provide critical information about the newborn's acid-base balance, oxygenation, and ventilation status. Post-term infants are at risk for hypoxia and acidosis, often due to placental insufficiency or meconium aspiration. However, obtaining ABGs can be invasive and might not be the first-line immediate action unless there are signs of severe distress.

C: Obtain a capillary blood glucose. Post-term infants are at increased risk for hypoglycaemia due to increased glucose utilization and possible depletion of glycogen stores. Hypoglycaemia can lead to serious complications if not promptly identified and managed. Therefore, checking blood glucose levels is a critical, non-invasive, and immediate step to ensure metabolic stability and prevent complications such as seizures and brain injury.

D: Provide blow-by oxygen. Blow-by oxygen is used to provide supplemental oxygen in a non-invasive manner and can help in cases of mild respiratory distress. Post-term infants can be at risk for respiratory issues, including meconium aspiration syndrome. However, this is usually applied when there is evidence of respiratory distress and not as a routine measure without specific indications.

A. Determine degree of skin elasticity. B. Measure muscle size and strength. C. Inspect appearance of the spine. D. Note 24-hour fluid intake and output.

Correct Answer is B

Explanation

A. Determine degree of skin elasticity: While decreased skin elasticity can be a sign of aging, it doesn't directly assess muscle tone or strength.

B. Measure muscle strength: This is the most appropriate next step to confirm the nurse's initial suspicion of weak muscles. Techniques like manual muscle testing can assess muscle strength.

C. Inspect appearance of the spine: Spinal issues can affect movement and coordination, but they wouldn't necessarily explain soft and boggy muscles in one arm.

D. Note 24-hour fluid intake and output: This might be relevant for overall health assessment but doesn't directly assess muscle tone or strength.

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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

Using the Ballard Gestational Age Assessment Tool, the nurse determines that a 15-minute old client has a gestational age of 42 weeks. Based on this finding, which intervention is most important for the nurse to implement?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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