Upon assessment of the client's lungs, the nurse hears continuous, high-pitched, musical sounds. This should be documented as:

fine crackles

wheezes

rhonchi

vesicular sounds

Answer and Explanation

The Correct Answer is B

A.   Fine crackles - Fine crackles are short, popping sounds usually heard during inspiration, indicative of fluid in the lungs.
B.   Wheezes - Wheezes are continuous, high-pitched musical sounds caused by narrowed airways, often seen in asthma, bronchitis, or other respiratory conditions.
C.   Rhonchi - Rhonchi are low-pitched, rattling sounds that occur when air flows through thick mucus or secretions in the larger airways.
D.   Vesicular sounds - Vesicular breath sounds are normal lung sounds heard over most lung fields during inspiration. They are not continuous and high-pitched.

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Correct Answer is D

Explanation

A. Instructing the client to remain quiet may reduce stress or activity but does not address the issue of the pacemaker not sensing properly.
B. Continuing to monitor without addressing the malfunction is inappropriate because this could lead to complications or inappropriate pacing.
C. Assessing blood pressure and pulse is important for patient safety but the priority is addressing the pacemaker's malfunction by notifying the healthcare provider.
D. The pacemaker should sense the client's intrinsic beats to avoid inappropriate pacing. If it is firing on the T wave or at inappropriate times, it indicates a sensing issue that needs to be addressed by the healthcare provider.

A. Perform carotid massage on the client B. Administer adenosine 12mg IV push STAT C. Prepare the client for electrical cardioversion D. Assess patient and obtain vital signs

Correct Answer is D

Explanation

A. Carotid massage can be used as a vagal maneuver for certain types of supraventricular tachycardia (SVT), particularly in stable patients. However, it is not recommended in cases where the patient has a history of cocaine use or is showing signs of instability because of the potential for triggering a serious event, like a stroke.
B. Adenosine is a medication commonly used for the treatment of SVT. However, it should be given with caution and only after assessing the patient's condition. In this case, the patient needs to be assessed first, including vital signs, level of consciousness, and overall stability, before any medications are administered.
C. Electrical cardioversion is indicated for unstable SVT (e.g., signs of hemodynamic instability such as hypotension, chest pain, or altered mental status). However, this patient is only reporting a "racing heart" and nervousness and has not yet been assessed for vital signs or other clinical symptoms.
D. The first step in this case should be to assess the patient's condition. This includes checking the vital signs, level of consciousness, and overall stability. Once this initial assessment is performed, the nurse can then determine whether medications or other interventions (like adenosine or cardioversion) are needed.

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			Male: 14- 17.3 g/dL
Hematocrit	26%	24%	Female: 36%-48% Male: 42%-52%
Platelets	35,000mm3	20,000mm3	150,000- 450,000mm3
RBC	4.5 mm3	3mm3	Female: 4.01-5.51 million/mm3 Male: 4.51-

Upon assessment of the client's lungs, the nurse hears continuous, high-pitched, musical sounds. This should be documented as:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who has had a temporary transvenous pacemaker inserted. The cardiac monitor shows pacemaker spikes occurring at various points in the client's own beats such as on the T wave. What action is the nurse's priority?

Correct Answer is D

Explanation

A client presents to the Emergency Department (ED) complaining of a "racing" heart and nervousness. The client also admits to a history of cocaine abuse. The cardiac monitor displays the rhythm below. Which nursing intervention should the nurse perform?

Correct Answer is D

Explanation

The nurse is caring for a client who is in the later stages of left-sided heart failure. Which chief complaint would the nurse expect the client to report?

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