While auscultating a client's trachea, the nurse hears a high, harsh sound with short inspiration and long expiration. How would the nurse document this finding?

Vesicular breath sounds

Adventitious breath sounds

Bronchial breath sounds

Bronchovesicular breath sounds

Answer and Explanation

The Correct Answer is C

A. Vesicular breath sounds are soft, low-pitched sounds heard over most of the lung fields, characterized by a longer inspiratory phase and shorter expiratory phase.
B. Adventitious breath sounds refer to abnormal breath sounds such as crackles, wheezes, and rhonchi, but the described sound is a normal breath sound in the tracheal region.
C. Bronchial breath sounds are correct. These are high-pitched, harsh sounds with a short inspiratory phase and a long expiratory phase, normally heard over the trachea.
D. Bronchovesicular breath sounds are moderate in pitch and intensity, heard over the major bronchi rather than the trachea. They have equal inspiration and expiration durations rather than a longer expiratory phase.

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Correct Answer is C

Explanation

A. Understanding the referral process is important for coordinating care but is not required to identify abnormal data and client strengths.
B. While knowing the medical prognosis can provide context, the nursing process focuses on holistic client assessment rather than medical diagnosis.
C. Drawing inferences about the client is correct because analyzing the collected data allows the nurse to recognize patterns, identify potential health problems, and determine the client’s strengths.
D. Knowledge of anatomy and physiology is valuable, but interpretation and clinical judgment (drawing inferences) are crucial for identifying abnormal data.

A. Inflate the blood pressure cuff 30 mmHg above the point where the radial pulse disappears. B. Assist the patient to a standing position for five to ten minutes. C. Palpate the radial artery and place your stethoscope lightly over this area. D. Measure the blood pressure cuff, ensuring that the cuff encircles 60% of the client’s arm.

Correct Answer is A

Explanation

A. Inflating the blood pressure cuff 30 mmHg above the point where the radial pulse disappears is correct. This method, known as the palpatory method, prevents auscultatory gap errors and ensures an accurate blood pressure reading.
B. Assisting the patient to a standing position for five to ten minutes is incorrect unless assessing for orthostatic hypotension. For routine blood pressure measurements, the client should be seated and at rest for at least five minutes.
C. Palpating the radial artery and placing the stethoscope lightly over this area is incorrect because blood pressure is auscultated over the brachial artery, not the radial artery.
D. Measuring the blood pressure cuff to encircle 60% of the client’s arm is incorrect. The correct guideline is that the cuff bladder should encircle at least 80% of the arm circumference, not 60%.

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While auscultating a client's trachea, the nurse hears a high, harsh sound with short inspiration and long expiration. How would the nurse document this finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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