A nurse assessing a client’s lung sounds hears continuous low-pitched harsh rattling sounds over the client’s trachea that are most evident on expiration and are decreased after coughing.
Which term is the appropriate choice to accurately document this lung sound?
Rhonchi.
Wheezing.
Crackles.
Pleural friction rub.
The Correct Answer is A
Rhonchi. Rhonchi are low-pitched, rattling sounds that indicate mucus in the larger airways. They are most evident on expiration and may decrease after coughing.
Choice B is wrong because wheezes are high-pitched, squeaking sounds that indicate narrowed small air passages. They are usually heard on both inspiration and expiration.
Choice C is wrong because crackles are short, high-pitched popping sounds that indicate fluid or inflammation in the alveoli. They are usually heard on inspiration.
Choice D is wrong because pleural friction rubs are creaking or grating sounds that indicate inflammation of the pleura. They are usually heard on both inspiration and expiration and do not change with coughing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
“I can’t promise that the information won’t be shared if your health or safety is involved.” This response by the nurse would be appropriate because it respects the client’s confidentiality while also acknowledging its limits of it. The nurse has a duty to report any information that may indicate a risk of harm to the client or others.
Choice A is wrong because it dismisses the client’s need to share something and implies that the nurse is not interested or trustworthy.
Choice B is wrong because it gives a false assurance of confidentiality and may lead to ethical dilemmas if the client reveals something that requires reporting.
Choice C is wrong because it does not address the issue of confidentiality and may give the impression that the nurse is trying to avoid the conversation.
Correct Answer is B
Explanation
My spouse will just have to put up with any new irritability. This statement indicates that the client requires further educational reinforcement about the medication because phenelzine is an antidepressant that should improve the mood and reduce irritability. The client may also need to be assessed for possible adverse effects of phenelzine, such as agitation, insomnia, or hypomania.
Choice A is wrong because it is a correct statement. Phenelzine is a monoamine oxidase inhibitor (MAOI) that can interact with foods that contain tyramine, such as cheese and caffeine, and cause a hypertensive crisis.
The client should avoid excessive amounts of these foods while taking phenelzine.
Choice C is wrong because it is also a correct statement. Phenelzine can cause orthostatic hypotension, which is a drop in blood pressure when changing positions.
The client should change positions slowly, as dizziness may occur.
Choice D is wrong because it is partially correct. Phenelzine can cause headaches, which may be a sign of a hypertensive crisis.
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