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. Clients with left-sided heart failure often experience symptoms like shortness of breath, fatigue, and fluid retention, which limit physical activity. However, they may still feel relatively comfortable when resting.
B. These symptoms are more commonly associated with allergic reactions or side effects of medications (such as ACE inhibitors) rather than heart failure.
C. This is not typical in the later stages of left-sided heart failure. In fact, clients may experience reduced urine output due to poor kidney perfusion.
D. Chest pain can occur due to ischemia, but this is not a hallmark symptom of left-sided heart failure, which is more characterized by dyspnea and fatigue.

A. Hemoglobin 10.1 g/di (normal Female: 11.7-15.5 g/dL: Male: 14-17.3 g/dL B. Brain natriuretic peptide 410 pg/mL (normal less than 100 pg/mL.) C. Sodium 132 mEq/L (normal 135 - 145 mEq/L) D. Fibrinogen level 201 mg/dL (normal 200-400 mg/dL)

Correct Answer is B

Explanation

A. A low hemoglobin level indicates anemia, not heart failure. While anemia can exacerbate heart failure, it is not the primary indicator.
B. BNP is a biomarker that is elevated in response to heart failure. A level above 100 pg/mL is suggestive of heart failure, and 410 pg/mL indicates significant heart stress and likely acute heart failure.
C. A low sodium level (hyponatremia) can occur in heart failure, but it is not specific enough to confirm the diagnosis. BNP is a more direct indicator of heart failure.
D. This is a normal fibrinogen level and does not indicate heart failure. Fibrinogen is more associated with clotting disorders.

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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:

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Naxlex Comprehensive Predictor Exams

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?

Correct Answer is A

Explanation

The nurse is caring for a client diagnosed with acute heart failure on the telemetry unit. Which laboratory result does the nurse know is most indicative of this diagnosis?

Correct Answer is B

Explanation

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