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 ["D","E"]

Explanation

A. Thoracic muscle tenderness is not directly associated with intercostal retraction. Muscle tenderness may occur due to overuse or strain but does not cause the retraction of the intercostal spaces. It is more related to musculoskeletal issues rather than respiratory conditions.
B. Barrel chest refers to an increased anterior-posterior chest diameter, often seen in chronic obstructive pulmonary disease (COPD) and emphysema. While barrel chest can indicate chronic lung conditions that might cause respiratory distress, it does not directly cause intercostal retraction.
C. Pectus excavatum, or "funnel chest," is a congenital deformity where the sternum is depressed inward, giving the chest a sunken appearance. However, pectus excavatum itself does not directly cause retractions but can be associated with increased respiratory effort.
D. Atelectasis refers to the collapse of part or all of a lung, leading to decreased lung volume. This condition often results in increased respiratory effort and can be associated with intercostal retractions as the body struggles to expand the collapsed lung areas and improve ventilation.
E. Obstruction of the airways, such as from a foreign body, mucus plug, or severe bronchoconstriction, can lead to increased respiratory effort as the client tries to overcome the obstruction. This increased effort often results in visible signs of respiratory distress, including intercostal retraction.

A. The nurse should count the respirations in an unobtrusive manner without informing the client. B. The nurse should inform the client that they are preparing to count the client's respirations. C. The nurse should place a hand on the client's chest to count respirations. D. The nurse should count when the respirations are audible.

Correct Answer is A

Explanation

A. Counting respirations unobtrusively helps ensure the client does not alter their breathing pattern due to the awareness of being observed. This method is generally preferred because it provides a more accurate assessment of the client's normal respiratory rate.
B. If the client is informed that their respirations are being counted, they may unconsciously alter their breathing pattern due to nervousness or the desire to appear normal. This could result in an inaccurate assessment of their true respiratory rate.
C. Placing a hand on the client's chest can be helpful in assessing the depth and evenness of respirations. However, this method might cause the client to become aware of the assessment and could lead to a change in their breathing pattern.
D. Counting respirations only when they are audible can be problematic. Audible respirations are not always present and may not accurately reflect the client’s full respiratory rate. This method may miss periods of quiet breathing and thus provide an incomplete assessment of the respiratory rate.

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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

The nurse is observing the respiratory effort of a client, and notes that the client's intercostal spaces are retracting on inspiration. The nurse will assess the client for the presence of which condition(s)? Select All That Apply

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

Explanation

The nurse is assessing the client's respiratory system. Which method will result in the most accurate assessment of the client's respiratory rate?

Correct Answer is A

Explanation

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