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 C

Explanation

A. Testing visual acuity assesses cranial nerve II (the optic nerve), not cranial nerve III.

B. Eliciting the gag reflex involves cranial nerves IX (glossopharyngeal) and X (vagus), not cranial nerve III.

C. Cranial nerve III (the oculomotor nerve) controls the constriction of the pupil in response to light, so checking the pupillary response to light is the appropriate assessment for this cranial nerve.

D. Observing for facial symmetry is more related to the function of cranial nerve VII (the facial nerve).

A. Bilateral bowel sounds in lower quadrants B. Symmetrical convex sphere shape C. Ecchymosis D. Concave umbilicus

Correct Answer is C

Explanation

A. Bilateral bowel sounds in the lower quadrants are normal and do not require further investigation unless they are abnormal in frequency or tone.

B. A symmetrical convex sphere shape of the abdomen can be a normal finding, especially in a well-nourished individual.

C. Ecchymosis (bruising) may be a sign of trauma, bleeding disorders, or other underlying health conditions that require further investigation.

D. A concave umbilicus may be normal or could indicate a past surgical history or conditions like malnutrition, but it doesn't inherently require investigation unless associated with other symptoms.

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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?

Nursing Test Bank

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