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. Bronchial breath sounds over a peripheral lung field B. Soft high-pitched expiratory wheezing with forced expiration. C. Absent breath sounds over one lung lobe D. Stridor

Correct Answer is D

Explanation

A. While abnormal bronchial breath sounds can indicate underlying pathology, they are not typically considered immediately life-threatening.
B. Wheezing is a common symptom of asthma and other conditions that cause airway narrowing. While it can be uncomfortable and distressing, it is not typically considered a life-threatening emergency.
C. Absent breath sounds can indicate a collapsed lung or other serious respiratory condition. However, it is not as immediately life-threatening as stridor, which indicates a severe airway obstruction.
D. Stridor is a high-pitched, wheezing sound caused by obstruction or narrowing of the upper airway (larynx or trachea). It is often associated with conditions like croup, epiglottitis, or an allergic reaction leading to airway swelling. Stridor indicates a significant obstruction in the upper airway that can rapidly lead to severe respiratory distress or compromise.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

You are performing a breast exam on an adult woman. You are inspecting the breasts for signs of retraction. What is the best position to observe for this?

Correct Answer is C

Explanation

Which assessment finding is most likely to be immediately life-threatening?

Correct Answer is D

Explanation

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