A nurse is assessing a sedated patient whose respiratory rate has fallen below 12 respirations per minute. The nurse identifies this condition as

Tachypnea

Bradypnea

Eupnea

Apnea

Answer and Explanation

The Correct Answer is B

A: Tachypnea refers to rapid breathing, typically defined as a respiratory rate exceeding 20 breaths per minute.
B: Bradypnea is characterized by abnormally slow breathing, with a respiratory rate below the normal range.
C: Eupnea describes normal breathing, with a respiratory rate within the typical range for the patient's age and health status.
D: Apnea is the absence of breathing, not merely a decreased rate, and is considered a medical emergency.

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Correct Answer is D

Explanation

A: Sonorous wheezes are low-pitched sounds and do not describe fine rales.

B: Musical or whistling sounds typically describe wheezes which are continuous and not the discontinuous sound of rales.
C: Noisy, snoring sounds are characteristic of rhonchi, not rales.

D: Fine rales are high-pitched, brief, and discontinuous crackling sounds that are often likened to the sound of hair being rubbed between fingers, indicative of fluid in the small airways.

A. The nurse applies pressure over a bony prominence of the foot for 2 seconds. B. The nurse percusses the tissue that appears edematous C. The nurse elevates the patient's feet on a pillow to decease swelling. D. The nurse charts, "Patient's feet appear to be swollen."

Correct Answer is A

Explanation

A: Applying pressure over a bony prominence helps assess for pitting edema, a common indicator of fluid retention causing swelling. This action provides objective data to confirm the patient's subjective observation.
B: Percussion is not typically used to assess edema. It is more suitable for assessing the density of underlying structures.
C: Elevating the feet may help alleviate swelling but does not confirm the presence of edema.
D: Documenting the observation is important, but further assessment is needed to confirm the patient's concern.

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A nurse is assessing a sedated patient whose respiratory rate has fallen below 12 respirations per minute. The nurse identifies this condition as

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Naxlex Comprehensive Predictor Exams

During auscultation, the nurse hears fine rales in the patient's lower lobes bilaterally. Fine rales are described as

Correct Answer is D

Explanation

The nurse enters the patient's room and the patient states, "I think my feet are swollen.". Which would be the nurse's next action?

Correct Answer is A

Explanation

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