Upon auscultating a client's lungs, the nurse notes there is a low-pitched, continuous respiratory sound that has a snoring quality. How should the nurse interpret and document the findings?

stridor

crackles

rhonchi

wheeze

Answer and Explanation

The Correct Answer is C

A. Stridor is a high-pitched sound typically heard in cases of airway obstruction.

B. Crackles are discontinuous sounds often associated with fluid in the alveoli.

C. Rhonchi are low-pitched, continuous sounds with a snoring quality, usually caused by secretions in the larger airways.

D. Wheezing is a high-pitched, continuous sound associated with narrowed airways.

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Correct Answer is D

Explanation

A. The dorsal surface of the hand is used for assessing temperature, not palpation.

B. The fingertips and palmar surface are used for deep palpation, not light palpation.

C. The palmar surface of the fingers can be used, but the finger pads provide more sensitivity for light palpation, especially when assessing the abdomen.

D. Finger pads are the best part of the hand for light palpation as they allow the nurse to assess tenderness and abdominal consistency accurately.

A. Evaluate chest expansion. B. Check client's response to questions about place and time. C. Check pupillary response to light. D. Assess the capillary refill.

Correct Answer is A

Explanation

A. In a trauma situation, airway, breathing, and circulation (ABCs) are the top priority. Evaluating chest expansion assesses the client’s ability to breathe and maintain oxygenation, making it the first action.

B. Checking the client's orientation is important but secondary to assessing breathing.

C. Pupillary response is an assessment that is important but comes after ensuring the client is breathing adequately.

D. Capillary refill are assessments that are important but come after ensuring the client is breathing adequately.

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Upon auscultating a client's lungs, the nurse notes there is a low-pitched, continuous respiratory sound that has a snoring quality. How should the nurse interpret and document the findings?

Nursing Test Bank

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