The practical nurse (PN) is auscultating a client's lung sounds. Which description should the PN use to document this sound? (Please listen to the audio clip provided).

Audio: [Wheezing sound]

Wheeze.

Rhonchi.

Stridor.

Fine crackles.

Answer and Explanation

The Correct Answer is A

Based on the provided audio clip, the sound heard is a high-pitched, continuous, musical sound. This sound is characteristic of wheezing, which is caused by the narrowing of the airways due to inﬂammation, bronchoconstriction, or the presence of mucus. Wheezing is commonly associated with conditions such as asthma, chronic obstructive pulmonary disease (COPD), or bronchitis.

Let's evaluate the other options:

b) Rhonchi: Rhonchi are low-pitched, coarse, ratling sounds that typically indicate the presence of mucus or ﬂuid in the larger airways. Rhonchi are often heard in conditions such as pneumonia or bronchitis, but they are diﬀerent from the high-pitched wheezing sound heard in the audio clip.

c) Stridor: Stridor is a high-pitched, harsh, and crowing sound that is heard during inspiration. It is often associated with upper airway obstruction, such as in cases of croup, epiglottitis, or a foreign body obstruction. The sound in the audio clip does not match the characteristics of stridor.

d) Fine crackles: Fine crackles are discontinuous, high-pitched, and brief sounds that are typically heard during inspiration. They are often described as "velcro-like" or "rice crispies" and are associated with conditions such as pulmonary fibrosis or congestive heart failure. The sound in the audio clip does not resemble fine crackles.

In summary, the sound in the provided audio clip is best described as wheezing, characterized by a high- pitched, continuous, musical sound. Therefore, the practical nurse (PN) should document this sound as "wheeze."

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Correct Answer is B

Explanation

This is the first action the PN should take when noticing that the UAP consistently records subnormal temperatures when using a tympanic thermometer. Observing how the UAP obtains temperatures will help the PN identify any errors or problems with the technique, equipment, or documentation. The PN can then provide feedback and guidance to the UAP to ensure accurate and reliable temperature measurements.

A. Repeat the heel stick for glucose in one hour. B. Offer nipple feedings of 10% dextrose. C. Begin frequent feedings of breast milk or formula. D. Assess for signs of hypocalcemia.

Correct Answer is C

Explanation

The correct answer is C.

Choice A reason:

Repeating the heel stick for glucose in one hour is not the best first action because it delays necessary treatment and the infant's glucose could drop further, potentially causing harm.

Choice B reason:

Offering nipple feedings of 10% dextrose is not the initial treatment of choice for neonatal hypoglycemia. Oral dextrose gel may be used, but the priority is to provide a source of nutrition, such as breast milk or formula, which offers more sustained glucose levels.

Choice C reason:

Begin frequent feedings of breast milk or formula. This is the first intervention to implement because the infant's current glucose level is below the normal neonatal range of [30 to 60 mg/dL or 1.7 to 3.3 mmol/L], indicating hypoglycemia, which is common in infants of mothers with gestational diabetes. Immediate feeding can help raise the blood glucose level safely.

Choice D reason:

Assessing for signs of hypocalcemia is not the immediate priority. While hypocalcemia can occur in newborns, particularly those with maternal diabetes, the current symptoms and glucose level suggest hypoglycemia is the primary concern. Signs of hypocalcemia include irritability, muscle twitches, jitteriness, tremors, and poor feeding, which can overlap with hypoglycemia symptoms. However, the heel stick glucose level clearly indicates hypoglycemia, which should be addressed first.

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The practical nurse (PN) is auscultating a client's lung sounds. Which description should the PN use to document this sound? (Please listen to the audio clip provided). Audio: [Wheezing sound]

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The practical nurse (PN) notices that one of the unlicensed assistive personnel (UAP) working in the long- term care facility consistently records subnormal temperatures when using a tympanic thermometer. Which action should the PN take first?

Correct Answer is B

Explanation

Correct Answer is C

Explanation

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The practical nurse (PN) is auscultating a client's lung sounds. Which description should the PN use to document this sound? (Please listen to the audio clip provided).

Audio: [Wheezing sound]