Upon auscultation of a client's lung sounds, the nurse notices a high-pitched wheezing sound. What condition is the likely cause of this sound?
Pleural effusion
Emphysema
Airway constriction
Hemoptysis
The Correct Answer is C
A. Pleural effusion involves the accumulation of fluid in the pleural space, which typically causes a decrease or absence of breath sounds, not wheezing.
B. Emphysema is a type of chronic obstructive pulmonary disease (COPD) that leads to damage of the alveoli and air sacs, which may result in wheezing, but it is not the most direct cause of high-pitched wheezing.
C. High-pitched wheezing is often a result of airway constriction or narrowing, which occurs in conditions like asthma, bronchitis, or anaphylaxis. The sound is caused by turbulent airflow through narrowed airways.
D. Hemoptysis refers to coughing up blood and does not cause wheezing. It is a symptom that may be associated with various respiratory conditions, but it does not directly cause the wheezing sound.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. While sterile drapes are important for maintaining a sterile field during the procedure, they do not directly address the issue of privacy.
B. Pulling the curtains around the client's bed is the most appropriate action to ensure privacy during the procedure. It creates a physical barrier to maintain confidentiality and dignity for the client while they undergo the lumbar puncture.
C. Closing the door to the client's room can also help maintain privacy but may not be as effective in a shared space like a hospital ward. Curtains are a more immediate and effective means of providing privacy.
D. Asking family members to leave the room may be necessary for the procedure but does not directly relate to privacy during the procedure. The focus should be on ensuring the environment is private by pulling curtains and closing doors.
Correct Answer is B
Explanation
A. Drinking 400 ml every hour is not a typical recommendation for bowel preparation with PEG. The client is usually instructed to drink a specific volume, but it is typically more than 400 ml at once and spread over a specific time frame, often 1-2 liters over several hours.
B. Abdominal bloating is a common side effect of polyethylene glycol-electrolyte solutions. The solution works by drawing water into the intestines to induce bowel movements, and this can lead to temporary bloating or discomfort.
C. While it is important to stay hydrated during the bowel prep, the recommendation to drink an additional liter of fluid is not typically included in the instructions. The PEG solution itself is designed to maintain fluid balance, and additional water may be advised, but this is not the standard guideline.
D. Bowel movements typically begin shortly after starting the PEG solution, often within 1-2 hours, rather than waiting 3 hours. The exact timing can vary, but 3 hours is longer than usual for the first bowel movement to occur.
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