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 A

Explanation

A. This statement indicates a need for further education. After receiving an ICD, clients must refrain from engaging in vigorous physical activities such as contact sports (e.g., football) for a longer period of time to avoid injury or triggering the defibrillator. A longer recovery period is typically recommended.
B. This is correct. Microwaves do not affect the function of an ICD, so it is safe to use one.
C. This is correct. The client should keep their cellphone at least 6 inches away from the ICD to avoid interference with the device.
D. This is correct. Clients may experience a sudden, forceful sensation similar to a kick or blow when the ICD delivers a shock to correct an arrhythmia.

A. Decreased D-dimer level B. Elevated fibrinogen level C. Decreased platelet count D. Prolonged prothrombin time (PT)

Correct Answer is A

Explanation

A. A decreased D-dimer level is a positive outcome, as D-dimer is elevated in DIC due to the formation of clots and the breakdown of fibrin. Lower levels indicate less clot formation and better control of the condition.
B. Fibrinogen levels are typically low in DIC due to consumption of clotting factors. Elevated fibrinogen in this case would be a negative indicator, suggesting that clotting is not resolving.
C. A decreased platelet count is a hallmark of DIC and indicates ongoing consumption of platelets due to widespread clotting. A decrease would not be a positive outcome.
D. A prolonged PT is another indicator of DIC, suggesting impaired clotting function. This is not a positive outcome.

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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 has provided teaching to a client who had an implantable cardioverter/defibrillator inserted. Which statement by the client indicates the need for further instruction?

Correct Answer is A

Explanation

The nurse is evaluating the outcomes for a client diagnosed with disseminated intravascular coagulation (DIC). Which laboratory value reflects a positive outcome?

Correct Answer is A

Explanation

The nurse is performing an admission assessment of an older adult client with a history of chronic heart failure. The client exhibits +2 pitting edema of the ankles and bibasilar crackles. Based on these findings what action should the nurse take next?

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