The nurse's auscultation of a client's lung fields reveals the presence of a wheeze. The nurse should recognize that this adventitious sound results from what pathophysiologic process?

Air being diverted from the trachea to the bronchi

Air passing through constricted passageways

Air increasing in turbulence in a wide passage

Air leaking from the alveoli into the pleural space

Answer and Explanation

The Correct Answer is B

A. Air being diverted from the trachea to the bronchi does not explain the cause of a wheeze. This is a normal part of airflow distribution.
B. Air passing through constricted passageways is correct. A wheeze is a high-pitched, musical sound that occurs when air flows through narrowed or obstructed airways, as seen in conditions like asthma, chronic obstructive pulmonary disease (COPD), or bronchitis.
C. Air increasing in turbulence in a wide passage is incorrect. Wheezing occurs due to airway narrowing, not widening.
D. Air leaking from the alveoli into the pleural space describes pneumothorax, which presents with absent breath sounds rather than wheezing.

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Correct Answer is A

Explanation

A. Reassessing the blood pressure measurement is correct because the nurse should always verify abnormal findings before taking further action. The initial reading could be due to equipment error, improper cuff size, or patient positioning.
B. Notifying the provider is incorrect at this time because the nurse should first confirm the accuracy of the reading before escalating concerns.
C. Rechecking the BP in 30 minutes is incorrect because if the reading is accurate, waiting 30 minutes could delay necessary interventions.
D. Having the patient care tech take the BP again is incorrect because the nurse should personally validate the abnormal finding rather than delegating it.

A. In the left lower quadrant. B. At the symphysis pubis. C. In the right upper quadrant. D. Above the umbilicus.

Correct Answer is B

Explanation

A. The left lower quadrant contains portions of the small and large intestines but is not the starting point for palpating the bladder.
B. The nurse should begin palpating at the symphysis pubis because the bladder is located in the lower abdomen. When distended, it rises above the pubic symphysis and can extend toward the umbilicus.
C. The right upper quadrant contains the liver and gallbladder but is not relevant to bladder assessment.
D. A significantly distended bladder may extend above the umbilicus, but the nurse should begin palpation at the symphysis pubis and move upward to assess for distention.

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The nurse's auscultation of a client's lung fields reveals the presence of a wheeze. The nurse should recognize that this adventitious sound results from what pathophysiologic process?

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Naxlex Comprehensive Predictor Exams

The nurse identifies that the patient care tech recorded the client's blood pressure as 78/52. The nurse recognizes this blood pressure is abnormally low for this client. What is the best response by the nurse?

Correct Answer is A

Explanation

A nurse is performing a comprehensive abdomen assessment including inspection, auscultation, and palpation. Upon palpation, the client's bladder is found to be distended. What location would the nurse begin palpating for the distended bladder?

Correct Answer is B

Explanation

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