Which of the following is not considered an adventitious lung sound upon auscultation:

Pleural friction rub

Rhonchi

Stridor

Vesicular

Answer and Explanation

The Correct Answer is D

A. Pleural friction rub: An adventitious sound that occurs due to inflamed pleural surfaces rubbing against each other during respiration.
B. Rhonchi: A low-pitched, continuous adventitious lung sound typically caused by airway obstruction or secretions.
C. Stridor: A high-pitched adventitious sound caused by upper airway obstruction.
D. Vesicular: A normal breath sound heard over most of the lung fields, characterized by a soft, low-pitched rustling sound.

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Correct Answer is D

Explanation

A. Loop the client's tubes carefully to prevent kinking: Tubes should not be unnecessarily looped, as this may cause obstruction or tension.
B. Clamp the tube when the client is ambulating: Clamping increases the risk of tension pneumothorax and should be avoided unless prescribed for specific procedures.
C. Place the client flat to avoid leaks in the tubing: This position may compromise lung expansion; semi-Fowler’s or Fowler’s position is preferred.
D. Keep the collection device below the client’s chest level: This position uses gravity to prevent backflow of fluid or air into the pleural space.

A. Assist the client to Fowler's position B. Promote removal of pulmonary secretions C. Increase the oxygen flow D. Obtain a specimen for arterial blood gases

Correct Answer is A

Explanation

A. Assist the client to Fowler's position: This position helps maximize lung expansion, making it easier for the client to breathe.
B. Promote removal of pulmonary secretions: Important but secondary to addressing immediate respiratory distress.
C. Increase the oxygen flow: This should only be done per provider order to avoid complications such as oxygen toxicity.
D. Obtain a specimen for arterial blood gases: This is a diagnostic step but not an immediate intervention for difficulty breathing.

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Which of the following is not considered an adventitious lung sound upon auscultation:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a client who has a newly inserted chest tube. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is caring for a client who is having difficulty breathing. The client is lying in bed and is already receiving oxygen therapy via nasal cannula. Which of the following interventions is the nurse's priority?

Correct Answer is A

Explanation

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