When auscultating over the apex of the client's lung field, what breath sound should the nurse expect to hear?
Bronchovesicular
Vesicular
Bronchial
Crackles
The Correct Answer is B
B. Heard over most of the lung fields, except for the major bronchi and the trachea.
Low intensity and pitch, with a longer inspiratory phase than expiratory phase. They are softer and more breezy in quality. Vesicular breath sounds are heard over the peripheral lung fields, including the apex (top) of the lungs.
A. Heard over the major bronchi, which are near the sternum and between the scapulae. They are of intermediate intensity and pitch, with equal inspiration and expiration phases. They are typically heard in the 1st and 2nd intercostal spaces along the sternal border and between the scapulae.
C. Heard over the trachea and larynx.
Characteristics: High intensity and pitch, with a short inspiratory phase and a longer expiratory phase. They are louder and harsher in quality, resembling the sound of air blowing through a hollow pipe.
D. Crackles are abnormal breath sounds that can be fine or coarse.
Fine crackles are high-pitched, short, popping sounds heard during inspiration, often due to fluid in the small airways or alveoli.
Coarse crackles are loud, low-pitched, bubbling sounds heard during inspiration, typically due to the presence of secretions in the larger airways.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B. This response acknowledges the urgency of the situation and seeks clarification on the appropriate administration technique. It demonstrates readiness to follow through with the medical resident's directive while ensuring safe and effective administration.
A. This response reflects hesitation and a concern about administering a medication that the nurse did not prepare or is unfamiliar with. In a critical situation like a "code blue," timely administration of medications as directed by the medical team is crucial for patient outcomes.
C. Checking IV patency is important to ensure the medication can be administered properly. However, in a "code blue" situation where time is critical, this step might unnecessarily delay administration of the medication.
D. This response indicates willingness to follow the directive given by the medical resident. It also emphasizes the importance of documenting and obtaining proper orders after the immediate crisis has been addressed.
Correct Answer is D
Explanation
D. This is the most appropriate goal for a client experiencing diarrhea. Diarrhea is characterized by loose or watery stools, and the goal of treatment is to restore normal stool consistency. This goal focuses on improving the symptoms and resolving the underlying cause of diarrhea, whether it's due to infection, dietary factors, or other reasons.
A. "Defecating regularly" does not necessarily imply improvement in diarrhea symptoms or resolution of the underlying cause. It is vague and does not provide a clear target related to diarrhea management.
B. Increasing ingestion of fruits may be beneficial for some individuals as fruits contain fiber and fluids that can help regulate bowel movements and maintain hydration. However, certain fruits high in fiber (e.g., apples, pears) may exacerbate diarrhea in some cases. This goal should be tailored based on the individual's tolerance and specific dietary needs.
C. This goal is not appropriate for managing diarrhea. Diarrhea leads to fluid loss and dehydration, so limiting fluid intake can worsen dehydration and electrolyte imbalances. Adequate fluid intake is crucial to replace lost fluids and maintain hydration during episodes of diarrhea.
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