The practical nurse (PN) is auscultating a client’s lung sounds and hears a high-pitched, continuous, musical sound during breathing. Which description should the PN use to document this 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 B
Explanation
Choice B rationale:
Observing for extrapyramidal symptoms, such as dystonia, is the most important intervention immediately after seclusion because haloperidol is an antipsychotic medication known to have the potential for causing extrapyramidal side effects. Identifying and managing these side effects promptly is crucial to ensure the client's safety.
Choice A rationale:
Releasing the client as soon as composure is regained may not be safe if the client is still at risk of harming themselves or others. Monitoring for the resolution of symptoms and stabilization is important before releasing the client.
Choice C rationale:
Securing the room with padded walls and minimal furnishings is not the immediate priority. While seclusion rooms should be safe and comfortable, observing for potential side effects takes precedence.
Choice D rationale:
Providing one-on-one observation at all times is a resource-intensive intervention and may not be necessary for all clients. Observing for extrapyramidal symptoms is more targeted and appropriate in this scenario.
Correct Answer is ["B","C","D","E"]
Explanation
The correct answers are Choices B, C, D, and E.
Choice A rationale: Dentures should remain in place to preserve facial structure and dignity. Removing them may cause facial collapse, distressing the family during viewing and violating postmortem presentation standards.
Choice B rationale: Gently closing the eyes prevents ocular drying and maintains a peaceful appearance. If eyelids resist closure, moistened cotton balls may be used temporarily to assist with natural positioning.
Choice C rationale: Placing a small pillow under the head elevates it, preventing blood pooling and facial discoloration due to livor mortis. It supports a natural, respectful presentation for family viewing.
Choice D rationale: Applying a body shroud ensures hygienic containment and visual dignity. It’s standard practice before transport and aligns with institutional protocols for respectful postmortem care.
Choice E rationale: Removing resuscitation equipment reduces trauma triggers for the family, restores environmental calm, and supports emotional closure. It also complies with facility standards for postmortem room preparation.
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