The nurse hears short, rattling, high-pitched sounds in the lower lobes of a client with pneumonia. Which finding should the nurse document?

Stridor.

Pleural rub.

Wheezing.

Crackles.

Answer and Explanation

The Correct Answer is D

D. The short, rattling, high-pitched sounds heard in the lower lobes of the client with pneumonia are indicative of crackles. Crackles are abnormal respiratory sounds that occur when air moves through fluid or mucus in the small airways or alveoli.

A. Stridor refers to a high-pitched, wheezing sound that occurs during inspiration or expiration and is typically associated with upper airway obstruction, such as in conditions like croup or foreign body aspiration.

B. Pleural rub refers to a grating or rubbing sound heard on auscultation that occurs when inflamed pleural surfaces rub against each other during respiration. It is commonly heard in conditions such as pleurisy or pleural effusion.

C. Wheezing refers to a high-pitched, musical sound heard during expiration that is typically associated with narrowing or obstruction of the airways, as seen in conditions like asthma or chronic obstructive pulmonary disease (COPD).

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

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

Explanation

A. Provide comfort measures such as topical warm application and tactile massage. Comfort measures can help alleviate chronic pain symptoms and provide relief to the client.

B. Implement a 24-hour schedule of routine administration of prescribed analgesic. Consistent administration of prescribed analgesics helps maintain pain control and manage chronic pain effectively.

E. Determine the client's subjective measure of pain using a numerical pain scale. Assessing the client's pain using a numerical pain scale allows for quantification of pain intensity, which helps guide pain management interventions and evaluate effectiveness.

A. Explain the purpose of a low bacteria diet. B. Send wound drainage for culture and sensitivity. C. Monitor the client's white blood cell count. D. Use standard precautions and wear a mask. E. Institute contact precautions for staff and visitors.

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

Explanation

Send wound drainage for culture and sensitivity.

Culturing the wound drainage helps identify the specific bacteria causing the infection and determine its antibiotic susceptibility, guiding appropriate treatment.

C. Monitor the client's white blood cell count.

Monitoring the white blood cell count helps assess for signs of infection and the body's immune response to the MRSA infection.

D. Use standard precautions and wear a mask.

Standard precautions should always be followed to prevent the transmission of infections in healthcare settings. Wearing a mask may be indicated if there is a risk of respiratory droplet transmission during wound care or other procedures.

E. Institute contact precautions for staff and visitors.

Contact precautions should be implemented to prevent the spread of MRSA to others. This includes wearing gloves and gowns when providing care, as well as educating staff and visitors about proper hand hygiene and infection control measures.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The nurse hears short, rattling, high-pitched sounds in the lower lobes of a client with pneumonia. Which finding should the nurse document?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is reviewing the admission assessment of a client with chronic pain, which intervention(s) should the nurse include in the client's plan of care? Select all that apply.

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

Explanation

A client who is paraplegic is admitted with a foul-smelling drainage from a sacral ulcer. The client is suspected to have a methicillin- resistant Staphylococcus aureus (MRSA) infection. Which nursing intervention(s) should the nurse include in the plan of care? Select all that apply.

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

Explanation

The nurse observes a client on a clear liquid diet has a cup of coffee on the breakfast tray. Which action should the nurse implement?

The nurse is assessing a client who reports a 3-day history of vomiting and diarrhea and experiencing difficulty in tolerating oral fluids. Which urine specific gravity value would the nurse expect to see on initial testing? Reference Range: Urine Specific Gravity [1.005 to 1.03]

The nurse is providing safety instructions to a client who is being discharged home with oxygen therapy. Which information provided by the client indicates understanding?

A client is in contact isolation due to a stage IV coccyx wound infected with methicillin resistant Staphylococcus aureus (MRSA). The nurse plans interventions to prevent multiple re-entries to the client's room. In which order should the nurse perform the interventions?

A nurse administers an opioid analgesic to a postoperative client who also has severe obstructive sleep apnea (OSA). Which intervention is most important for the nurse to implement before leaving the client alone?

The healthcare provider prescribes allopurinol 0.2 grams PO for a client with gout. The available medication is labeled, "Allopurinol tablets 200 mg." How many tablets should the nurse administer? (Enter numerical value only, rounded to the nearest whole number.)

A female client with metastatic breast cancer is admitted with shortness of breath and pleural effusions. The client has a living will and the family is requesting hospice information. Which information should the nurse provide regarding hospice? Select all that apply.

The nurse is demonstrating three-point gait crutch walking to an older adult client who broke a foot while playing soccer with the grandchildren. Which behavior indicates that the client understands proper crutch walking?