The nurse is assessing a client with chronic obstructive pulmonary disease (COPD) and auscultates moist, rumbling sounds that improve after the client coughs. How will the nurse document the lung sounds?

Wheezes

Rhonchi

Crackles

Pleural friction rub

Answer and Explanation

The Correct Answer is B

Choice A reason: Wheezes are high-pitched, musical sounds caused by narrowed airways, common in asthma or COPD exacerbations. They do not clear with coughing and are not moist or rumbling, making this an incorrect description for the lung sounds heard, which improve after coughing in this COPD client.

Choice B reason: Rhonchi are low-pitched, moist, rumbling sounds caused by secretions in larger airways, often in COPD. They improve with coughing as secretions are mobilized, matching the description provided. This makes rhonchi the accurate term for documenting these lung sounds, reflecting secretion accumulation in COPD.

Choice C reason: Crackles are fine or coarse popping sounds caused by fluid in smaller airways or alveoli, often in pneumonia or heart failure. They do not clear with coughing and are not rumbling, making crackles an incorrect choice for the moist, rumbling sounds that improve after coughing.

Choice D reason: Pleural friction rub is a grating sound caused by inflamed pleural surfaces, often in pleurisy. It is not moist or rumbling and does not improve with coughing, making it an inappropriate description for the lung sounds heard in this client with COPD, which are secretion-related.

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Correct Answer is D

Explanation

Choice A reason: Urine specific gravity of 1.010 is normal (1.005–1.030), indicating adequate hydration. Dehydration elevates specific gravity (>1.030) due to concentrated urine, so this client does not show dehydration signs, making this an incorrect choice for requiring fluid replacement interventions.

Choice B reason: Weight gain of 2.6 lbs in 24 hours suggests fluid retention, not dehydration. This may indicate hypervolemia, possibly from heart or renal failure, requiring diuretics. Dehydration involves weight loss, making this client’s finding inconsistent with dehydration needing intervention.

Choice C reason: Hematocrit of 45% is normal (38–50% males, 36–46% females). Dehydration elevates hematocrit due to hemoconcentration from reduced plasma volume. Normal hematocrit does not indicate dehydration, making this client an incorrect choice for requiring dehydration-specific fluid interventions.

Choice D reason: A BUN of 24 mg/dL is elevated (normal 7–20 mg/dL), indicating dehydration, as reduced renal perfusion concentrates blood urea nitrogen. This reflects hypovolemia, requiring fluid replacement to restore renal function and prevent acute kidney injury, making this client the priority for dehydration intervention.

A. Ask the UAP to reassess the client B. Reassess the client to validate these vital signs C. Notify the healthcare provider of these vital signs D. Sit the client up in bed

Correct Answer is B

Explanation

Choice A reason: Asking the UAP to reassess delays accurate assessment by a qualified nurse. Pulse 122 and BP 98/72 suggest tachycardia and hypotension, requiring professional validation and intervention, making this less appropriate than direct nurse reassessment and provider notification.

Choice B reason: Reassessing the client validates vital signs (pulse 122, BP 98/72), indicating tachycardia and hypotension, possibly from hypovolemia or sepsis. Accurate nurse assessment ensures reliable data for diagnosis, preventing complications like shock, making this a critical action in this scenario.

Choice C reason: Notifying the provider is essential, as tachycardia (pulse 122) and hypotension (BP 98/72) suggest serious conditions like hypovolemia or sepsis. Prompt reporting ensures timely interventions, such as fluids or diagnostics, preventing deterioration, making this necessary alongside reassessment.

Choice D reason: Sitting the client up may improve breathing but does not address tachycardia and hypotension, which suggest hypovolemia or other issues. These vital signs require reassessment and provider notification to diagnose and treat the cause, making positioning less urgent.

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The nurse is assessing a client with chronic obstructive pulmonary disease (COPD) and auscultates moist, rumbling sounds that improve after the client coughs. How will the nurse document the lung sounds?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing four clients. Which client requires interventions for dehydration?

Correct Answer is D

Explanation

The unlicensed assistive personnel (UAP) notifies the nurse of these vital signs for a client on the medical-surgical unit: temperature 97.6°F, respirations 20, pulse 122, and BP 98/72. Which actions should the nurse do next?

Correct Answer is B

Explanation

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