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.
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."
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
- A mastectomy is a surgical procedure that involves the removal of all or part of the breast, usually to treat breast cancer. A mastectomy can have a significant impact on a woman's physical, emotional, and psychological well-being, as it may affect her body image, self-esteem, sexuality, and identity.
- A mastectomy incision is the wound that results from the surgery, which may vary in size, shape, and location depending on the type and extent of the mastectomy. The incision may be closed with stitches, staples, or glue, and covered with a dressing or bandage.
- The first dressing change is usually done within 24 to 48 hours after the surgery, and it involves removing the old dressing, inspecting the incision for any signs of infection or complications, cleaning the wound, applying a new dressing, and educating the client about wound care .
- When the practical nurse (PN) tells the client that her mastectomy incision is healing well, but the client refuses to look at the incision and refuses to talk about it, this may indicate that the client is experiencing denial, fear, anger, grief, or depression due to the loss of her breast. These are normal and common reactions that may occur at different stages of the recovery process.
- The best response by the PN to the client's silence is to acknowledge and respect the client's feelings, provide support and reassurance, and offer assistance when needed. This will help to establish trust and rapport with the client, as well as promote her coping and adjustment.
- Therefore, option A is the best answer, as it shows empathy and respect for the client's feelings, while also informing the client that the PN will be available when she is ready to look or talk about the mastectomy. Option A also implies that the PN will not pressure or force the client to do something that she is not comfortable with.
- Options B, C, and D are incorrect answers, as they do not show empathy or respect for the client's feelings, and they may cause more harm than good.
Correct Answer is A
Explanation
The finding that is the highest priority for the PN to report to the charge nurse is the blood urea nitrogen (BUN) level of 75 mg/dL or 12.9 mmol/L. This result indicates an elevated BUN level, which can be indicative of impaired kidney function. In a client receiving chemotherapy, an elevated BUN level may suggest chemotherapy-induced nephrotoxicity or other kidney-related complications. Prompt reporting is crucial to ensure appropriate intervention and management of the client's kidney function.
B. While the platelet count of 135,000/mm3 or 135 x 109/L is slightly below the normal reference range, it does not pose an immediate life-threatening risk. However, it should still be monitored and reported to the healthcare team for ongoing assessment and evaluation.
C. Decreased deep tendon reflexes may be an expected side effect of certain chemotherapy medications or a manifestation of neurotoxicity. While this finding should be documented and monitored, it is not as urgent as the elevated BUN level.
D. Periodic nausea and vomiting are common side effects of chemotherapy, but they may also be indicative of other underlying issues such as dehydration, electrolyte imbalances, or gastrointestinal complications. While this finding should be addressed and managed, it is not the highest priority compared to the elevated BUN level.
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