The nurse is preparing to auscultate the breath sounds of a client for an asthma exacerbation. Which breath sounds does the nurse anticipate to find upon assessment?

High pitch continuous sounds on inspiration and expiration.

High pitched short crackling

Low pitch continuous rattling on inspiration and expiration.

Low pitched grating and rubbing on inhalation and exhalation.

Answer and Explanation

The Correct Answer is A

A.   This option describes wheezes, which are high-pitched continuous sounds often heard on both inspiration and expiration. Wheezes are commonly associated with asthma because they result from the narrowing of the airways, causing turbulent airflow.
B.   This description refers to crackles (or rales), which are short, high-pitched sounds often heard on inspiration. Crackles are typically associated with conditions such as pneumonia, congestive heart failure, or other forms of pulmonary edema. They are not as specific to asthma as wheezes are.
C.   This option describes rhonchi, which are low-pitched, continuous rattling sounds that may occur on both inspiration and expiration. Rhonchi are often associated with airway obstruction due to secretions or mucus and can be heard in conditions such as chronic bronchitis.
D.   This option describes pleural friction rubs, which are low-pitched, grating sounds heard during both inhalation and exhalation. Pleural friction rubs occur when the pleural layers become inflamed and rub against each other.

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Correct Answer is C

Explanation

A. This position is useful for inspecting the overall shape and size of the breasts, but it may not be the best for detecting retractions.
B. This position can help identify changes in the breast tissue, but it may not be as effective as raising one arm overhead for detecting retractions.
C. Raising one arm over the head tenses the muscles in the breast and chest, which can make any retractions more visible. Retraction is often characterized by dimpling or pulling of the skin, which may be more noticeable when the breast tissue is taut.
D. This position can be helpful for examining the breasts for other abnormalities, but it may not be the best for detecting retractions.

A. The client sitting up and leaning over the bedside table, B. Fine bilateral basilar crackles. C. A respiratory rate of 9 breaths/min. D. A large barrel chest.

Correct Answer is C

Explanation

A. This position is often seen in clients with chronic respiratory conditions like emphysema. It is called the tripod position and can help the client breathe more easily by expanding the chest and reducing the work of breathing. While this position indicates the client is experiencing difficulty breathing, it is not an immediate emergency but rather a sign of their chronic respiratory condition.

B. Fine crackles (or rales) are abnormal lung sounds that can indicate fluid in the alveoli. In emphysema, crackles are not typical and may suggest a complication such as pulmonary edema or infection.
However, if these crackles are not severe and the client’s overall condition is stable, it may not be the
most urgent issue compared to other findings.
C. A respiratory rate of 9 breaths per minute is considered bradypnea, which is significantly lower than the normal range (12-20 breaths/min). For a client with chronic emphysema on oxygen therapy, bradypnea is a concerning finding because it indicates inadequate respiratory drive and potential respiratory depression.
D. A barrel chest is a common physical finding in clients with chronic emphysema due to chronic air trapping and lung overexpansion. It reflects long-standing changes in the chest structure due to the disease. While it is a notable finding, it is a chronic manifestation of emphysema and not an immediate concern in the context of acute clinical status.

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The nurse is preparing to auscultate the breath sounds of a client for an asthma exacerbation. Which breath sounds does the nurse anticipate to find upon assessment?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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