Upon assessment of a client's lungs, the nurse notes intermittent, high-pitched popping sounds heard, more notably on inspiration. This refers to which adventitious lung sound:
Rhonchi
Crackles/Rales
Wheezing
Stridor
The Correct Answer is B
A. Rhonchi: Rhonchi are low-pitched, snoring or gurgling sounds often caused by secretions in larger airways and are typically continuous, not high-pitched popping.
B. Crackles/Rales: Crackles (rales) are intermittent, high-pitched popping or bubbling sounds heard primarily on inspiration, commonly from alveolar fluid or opening of collapsed airways.
C. Wheezing: Wheezes are continuous, musical, high-pitched sounds produced by narrowed airways (bronchoconstriction) and are usually more continuous than intermittent popping.
D. Stridor: Stridor is a high-pitched, harsh inspiratory sound from upper-airway obstruction (larynx/trachea), not the intermittent inspiratory popping described.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. The client has just ambulated back from the bathroom: Recent physical activity can transiently raise temperature, but it is not a strong contraindication to oral measurement; allow a short rest if possible.
B. The client reports he sleeps supine: Sleep position is irrelevant to the suitability of oral temperature measurement.
C. The client has dentures: Dentures should be removed for oral temperature placement or the probe positioned properly under the tongue; dentures alone are not an absolute contraindication but require brief adjustment.
D. The client has just drank a hot beverage: Recent ingestion of hot (or cold) liquids will falsely alter oral temperature readings; wait (usually 15–30 minutes) before using an oral thermometer.
Correct Answer is B
Explanation
A. Leave the room and notify the nursing supervisor: Leaving the patient delays immediate wound protection and would abandon a patient with an acute surgical emergency; the priority is to protect exposed viscera and get help.
B. Treat the evisceration by covering area with sterile gauze pad soaked with sterile saline: Covering the exposed bowel with sterile, saline-moistened dressings reduces contamination, prevents tissue drying, and is the immediate priority while calling the surgeon/rapid response and keeping the patient NPO and supine.
C. Notify the patient's family: Informing family is important later, but it is not the immediate clinical action; stabilize and protect the patient first.
D. Instruct her to cough and deep breathe: Coughing increases intra-abdominal pressure and can worsen evisceration - this should be avoided.
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