A nurse is auscultating the breath sounds of a client who has asthma. When the client exhales, the nurse hears continuous high-pitched squeaking sounds. The nurse should document this as which of the following adventitious breath sounds?

Wheezes

Rhonchi

Crackles

Stridor

Answer and Explanation

The Correct Answer is A

A. Wheezes are high-pitched continuous sounds heard during exhalation, commonly associated with asthma due to narrowed airways.

B. Rhonchi are low-pitched sounds caused by airflow obstruction in the larger airways and typically clear with coughing.

C. Crackles (or rales) are high-pitched sounds heard during inhalation and are often associated with fluid in the lungs, such as in pneumonia or heart failure.

D. Stridor is a high-pitched sound heard during inspiration and is often indicative of upper airway obstruction.

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Correct Answer is D

Explanation

A. Quaternary prevention focuses on preventing over-medicalization or unnecessary interventions in health care.

B. Tertiary prevention aims to reduce the impact of an already established disease, such as rehabilitation.

C. Secondary prevention focuses on early detection of disease to prevent progression, such as through screenings.

D. Primary prevention aims to prevent the onset of disease or injury before it occurs. Immunizations and water fluoridation are both measures that help prevent disease in the general population before it starts.

A. Place the client in a room with negative airflow. B. Wear a gown when providing care to the client. C. Ensure the client's room has HEPA filtration. D. Wear a mask when providing care to the client.

Correct Answer is D

Explanation

A. Inspection is usually done first to observe any obvious abnormalities, but it is not the immediate action when the client reports pain.

B. Palpation should be done last, as it can cause discomfort or alter the findings of other assessment techniques.

C. Auscultating the abdomen should be done second after inspection. This is recommended because bowel sounds should be assessed before palpation, as palpation may alter the sounds.

D. Percussion can follow auscultation, but it is not the immediate action.

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A nurse is auscultating the breath sounds of a client who has asthma. When the client exhales, the nurse hears continuous high-pitched squeaking sounds. The nurse should document this as which of the following adventitious breath sounds?

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A nurse is auscultating the breath sounds of a client who has asthma. When the client exhales, the nurse hears continuous high-pitched squeaking sounds. The nurse should document this as which of the following adventitious breath sounds?

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