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).

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Correct Answer is D

Explanation

D. Thoroughly drying between the toes is essential for preventing moisture buildup, which can contribute to the development of fungal infections such as athlete's foot. In a client with diminished circulation in the lower extremities, ensuring proper drying between the toes becomes even more critical to reduce the risk of skin breakdown and infection.

A, B, C- drying the dorsum, heels and ankle regions is important to prevent maceration of skin but they are not the areas commonly affected by infection in cases of compromised circulation.

A. Switch to a non-rebreather mask. B. Verify placement of pulse oximeter. C. Increase the oxygen to 3 L/minute. D. Remove nasal cannula.

Correct Answer is B

Explanation

B. When the oxygen saturation is lower than expected, the nurse's first action should be to verify the accuracy of the reading by ensuring the proper placement and functioning of the pulse oximeter. This involves checking that the pulse oximeter probe is securely attached to the client's finger or other appropriate site and that there are no obstructions or interference affecting the reading.

A. A non-rebreather mask delivers higher concentrations of oxygen compared to a nasal cannula and is typically used when a client requires higher levels of oxygen supplementation. However, switching to a non-rebreather mask may not be appropriate without further assessment.

C. Increasing the oxygen flow rate to 3 L/minute would deliver a higher concentration of oxygen to the client, potentially improving oxygen saturation. However, increasing the oxygen flow should be done cautiously and based on clinical assessment to avoid oxygen toxicity.

D. Removing the nasal cannula would deprive the client of supplemental oxygen, which may not be appropriate if the client's oxygen saturation is already low. Oxygen supplementation is typically provided to improve oxygenation and support vital organ function.

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

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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