A nurse is assessing a client who has chronic bronchitis. Which of the following percussion sounds should the nurse expect?

Dullness

Tympany

Resonance

Flatness

Answer and Explanation

The Correct Answer is C

Choice A reason: Dullness on percussion typically indicates increased lung density, such as in conditions where lung tissue is consolidated or fluid-filled. This sound is heard in cases of: Pneumonia (due to alveolar consolidation) Pleural effusion (fluid in the pleural space) Lung tumors (solid masses in lung tissue) Since chronic bronchitis is primarily an airway disease characterized by inflammation and mucus production rather than lung consolidation or fluid accumulation, dullness is not an expected finding..

Choice B reason: Tympany is usually heard over air-filled structures and is not a percussion sound typically associated with chronic bronchitis.

Choice C reason:

Resonance is the normal percussion sound heard over healthy lung fields, indicating air-filled alveoli. Since chronic bronchitis does not cause significant air trapping or lung consolidation, percussion remains resonant rather than hyperresonant (as in emphysema) or dull (as in pneumonia). Thus, resonance is the expected finding in chronic bronchitis because the lung parenchyma remains relatively unaffected despite the chronic airway inflammation.

Choice D reason: Flatness is heard over very dense tissue, such as muscle or bone, and is not characteristic of chronic bronchitis.

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Correct Answer is B

Explanation

Choice A reason: The medication administration record is an important document, but it is not the primary source for verification before administering blood products. It is used to record the administration after the fact.

Choice B reason: The identification wristband is the priority source for verification. It contains the client's essential information, such as name and hospital ID, which must match the blood product label to ensure patient safety⁸.

Choice C reason: The order sheet contains the physician's orders, which is crucial for verifying what has been prescribed but is secondary to the identification wristband for the actual administration process.

Choice D reason: The chart contains a comprehensive record of the client's medical history and care but is not the primary source for verification when administering blood products.

A. Prepare to administer a vasopressor. B. Administer an anticholinesterase medication. C. Prepare the client for intubation. D. Instruct the client to perform pursed lip breathing.

Correct Answer is C

Explanation

The correct answer is: c. Prepare the client for intubation.

Choice A: Prepare to administer a vasopressor

Reason: Vasopressors are typically used to manage hypotension (low blood pressure) and are not a standard treatment for myasthenic crisis. Myasthenic crisis primarily involves respiratory muscle weakness, which can lead to respiratory failure, rather than issues with blood pressure.

Choice B: Administer an anticholinesterase medication

Reason: While anticholinesterase medications like pyridostigmine are used to manage myasthenia gravis, they are generally not recommended during a myasthenic crisis. During a crisis, the focus is on stabilizing the patient, often requiring more immediate interventions such as intubation and mechanical ventilation.

Choice C: Prepare the client for intubation

Reason: Intubation is a critical intervention in a myasthenic crisis due to the risk of respiratory failure. The crisis is characterized by severe muscle weakness, including the muscles that control breathing. Intubation ensures that the airway is protected and that the patient can receive adequate ventilation.

Choice D: Instruct the client to perform pursed lip breathing

Reason: Pursed lip breathing is a technique used to improve breathing efficiency in conditions like chronic obstructive pulmonary disease (COPD). However, it is not appropriate for managing a myasthenic crisis, where the primary issue is severe muscle weakness leading to respiratory failure.

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A nurse is assessing a client who has chronic bronchitis. Which of the following percussion sounds should the nurse expect?

Nursing Test Bank

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