The nurse is preparing to auscultate the lung sounds of a young adult. Which sound will the nurse expect to hear over most of the client's lungs?
Tracheal
Vesicular
Bronchovesicular
Bronchial
The Correct Answer is B
Choice A Reason:
Tracheal sounds are harsh, high-pitched breath sounds typically heard over the trachea in the neck. They are not expected to be heard over the peripheral lung fields of a young adult during a routine lung auscultation.
Choice B Reason:
Vesicular breath sounds are the normal sounds heard over most of the lung fields. They are characterized by a soft, low-pitched, rustling sound during inhalation and are softer during exhalation. These sounds are created by air moving through the smaller airways such as the bronchioles and alveoli.
Choice C Reason:
Bronchovesicular sounds are heard over the major bronchi and are characterized by a moderate pitch and intensity. They are typically heard between the first and second intercostal spaces at the sternal border anteriorly and between the scapulae posteriorly, not over most of the lung fields.
Choice D Reason:
Bronchial breath sounds are high-pitched and louder than vesicular sounds, with a hollow quality, and are normally heard over the manubrium. If heard over the peripheral lung fields, they may indicate lung consolidation or other abnormalities.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice a reason:
Assisting the client to a sitting position is not the best action to ensure that bowel sounds can be heard. For abdominal auscultation, the patient should be lying down in a supine position to relax the abdominal muscles, which facilitates the hearing of bowel sounds.
Choice b reason:
Percussion of the abdomen before auscultation is not recommended as the best initial action. Percussion can stimulate bowel motility, which may alter the natural bowel sounds that the nurse is attempting to assess.
Choice c reason:
Reducing all environmental noise is the best action to ensure that bowel sounds can be heard clearly. Environmental noise can mask the subtle sounds of bowel motility, and minimizing distractions allows for a more accurate assessment of bowel activity.
Choice d reason:
Palpating the region before auscultating is not the best action because palpation can also stimulate bowel motility and potentially alter the bowel sounds. Auscultation should be performed before palpation during the abdominal examination to avoid this issue.
Correct Answer is D
Explanation
Choice a reason:
Eye malalignment is a general term that refers to any form of misalignment of the eyes, which can include esotropia but is not specific to it. Esotropia is a type of strabismus where there is a specific pattern of eye malalignment.
Choice b reason:
Eye turning outward is known as exotropia, which is the opposite of esotropia. In exotropia, one or both eyes turn outward away from the nose, which is not characteristic of esotropia.
Choice c reason:
Eye oscillating refers to nystagmus, a condition where the eyes make repetitive, uncontrolled movements, often resulting in reduced vision and depth perception. While nystagmus can occur in conjunction with esotropia, it is not a defining characteristic of esotropia itself.
Choice d reason:
Eye turning inward is the hallmark of esotropia. In this condition, one or both eyes turn inward towards the nose. It can be constant or intermittent and may affect one eye or alternate between both eyes. Esotropia can be comitant, meaning the degree of deviation is the same in every direction of gaze, or incomitant, where the deviation varies with gaze direction.
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