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 D

Explanation

A. "Lungs clear to auscultation bilaterally" is a physical assessment finding and should be documented in the physical examination, not the review of systems (ROS).
B. "High school diploma plus 2 years of college" is part of the social history, not the ROS.
C. "Caregiver reliable source of information" pertains to the history's reliability or source of information, not the ROS.
D. "Menarche at age 13" is correct because the ROS consists of subjective information reported by the client regarding different body systems, including the reproductive system.

A. The right lung is approximately one third larger than the left lung. B. The lower lobes of both lungs are primarily located toward the anterior chest wall. C. The right lung has three lobes, while the left lung has two lobes. D. The lungs are structurally symmetrical but functionally different.

Correct Answer is C

Explanation

A. The right lung is larger than the left to accommodate the heart’s position, but it is not precisely one third larger.
B. The lower lobes of both lungs are primarily located toward the posterior chest wall, not the anterior. When auscultating breath sounds in the lower lobes, the nurse should focus on the posterior thorax.
C. The right lung has three lobes (upper, middle, and lower), while the left lung has two lobes (upper and lower). This anatomical difference is important for respiratory assessment and auscultation.
D. The lungs are not structurally symmetrical; the left lung is smaller due to the cardiac notch. While there are minor functional differences, the primary distinction is anatomical.

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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

A nurse has completed the review of systems component of the client's health history. Which assessment finding should the nurse document under the review of systems?

Correct Answer is D

Explanation

The nurse is preparing to perform a focused respiratory assessment on a client. The nurse should be cognizant of what anatomical characteristic of the lungs?

Correct Answer is C

Explanation

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