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 B

Explanation

A. Pneumonia typically presents with fever, productive cough, and crackles rather than wheezing and tripod positioning.
B. Chronic emphysema is correct. The tripod position (leaning forward, hands on knees) is a classic sign of severe obstructive lung disease, such as emphysema or COPD. Wheezing and dyspnea at rest suggest air trapping and difficulty exhaling, which are hallmarks of this condition. The oxygen saturation of 91% is common in COPD patients due to chronic hypoxemia.
C. Pneumothorax presents with sudden onset chest pain, absent breath sounds on one side, and tracheal deviation (if severe) rather than wheezing.
D. Congestive heart failure can cause dyspnea but typically presents with crackles due to pulmonary edema rather than wheezing and tripod positioning.

A. Have the client lay on their left side. B. Ask the client to exhale and hold their breath. C. Encourage the client to raise their head off the pillow. D. Assist the client in flexing their knees.

Correct Answer is D

Explanation

A. Lying on the left side does not aid in abdominal palpation and may not provide additional diagnostic information.
B. Asking the client to exhale and hold their breath is useful in certain liver or gallbladder assessments but is not relevant for general abdominal palpation.
C. Raising the head off the pillow is a technique used to assess for diastasis recti or hernias but is not beneficial for assessing right lower quadrant pain.
D. Assisting the client in flexing their knees is correct because it relaxes the abdominal muscles, reducing guarding and making palpation more effective. This is especially important when assessing for conditions like appendicitis.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing an older adult client in the emergency room. Upon assessment, the nurse notes that the client is in the tripod position, has dyspnea at rest, wheezing upon auscultation, and an oxygen saturation level of 91%. What significant health problem might the nurse suspect?

Correct Answer is B

Explanation

Correct Answer is D

Explanation

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