The nurse is auscultating the lungs of a sleeping client and hears short, popping, crackling breath sounds that stop after a few breaths. The nurse recognizes that these breath sounds are:
Atelectatic crackles that do not have a pathologic cause.
Vesicular breath sounds.
Fine wheezes.
Fine crackles and may be a sign of pneumonia.
The Correct Answer is A
A. Atelectatic crackles that do not have a pathologic cause:
Atelectatic crackles are short, popping, crackling sounds heard during auscultation. They occur in individuals who are in a supine position and disappear after a few breaths. These crackles are not indicative of any pathological condition; they are common when the lungs are not fully aerated, especially when a person is lying down.
B. Vesicular breath sounds:
Vesicular breath sounds are normal lung sounds heard over the peripheral lung areas. They are soft, low-pitched, and continuous throughout inspiration and part of expiration. Vesicular breath sounds are the typical sounds heard during routine breathing and are not associated with crackling or popping noises.
C. Fine wheezes:
Wheezes are high-pitched whistling sounds heard during expiration. They occur due to narrowed airways and are commonly associated with conditions like asthma or bronchoconstriction. Fine wheezes suggest a partial obstruction in the smaller airways, causing turbulent airflow, leading to the characteristic sound.
D. Fine crackles and may be a sign of pneumonia:
Fine crackles are high-pitched, discontinuous, crackling sounds heard during inspiration. They can occur due to the sudden opening of small airways, and their presence may indicate fluid in the lungs or lung inflammation. Fine crackles are often associated with conditions such as pneumonia, heart failure, or interstitial lung diseases.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Fifth intercostal space, left of the midclavicular line: This placement is used to auscultate the mitral valve, which is best heard at the apex of the heart. The mitral valve sounds are typically heard around the fifth intercostal space, midclavicular line.
B. Left lower sternal border: This placement is used to auscultate the tricuspid valve, which is best heard at the lower left sternal border.
C. Second left intercostal space: This is the correct placement for auscultating the pulmonic valve. The pulmonic valve sounds are best heard at the second left intercostal space, which is close to the upper left sternal border.
D. Second right intercostal space: This placement is used to auscultate the aortic valve, which is best heard at the second right intercostal space, close to the upper right sternal border.
Correct Answer is A
Explanation
A. Fifth left intercostal space at the midclavicular line:
Explanation: The apical pulse, or the point of maximal impulse (PMI), is typically located at the fifth intercostal space at the midclavicular line on the chest. This is the area where the heartbeat is best heard using a stethoscope in most adults.
B. Third left intercostal space at the midclavicular line:
Explanation: This location is too high for the apical pulse. The heart's apex is generally not found at the third intercostal space; it's lower, closer to the fifth intercostal space.
C. Fourth left intercostal space at the sternal border:
Explanation: This location is not the typical site for auscultating the apical pulse. The PMI is usually heard at the midclavicular line, not at the sternal border.
D. Under the left breast at the midclavicular line:
Explanation: This position is not precise enough for auscultating the apical pulse. The specific intercostal space (fifth) and midclavicular line are crucial for accurate assessment.
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