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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Decreased muscle mass is a normal age-related musculoskeletal change. This can lead to reduced strength and mobility in older adults.
B. Chest width typically remains stable, though changes in lung function or posture may occur with aging.
C. Vertebral disks tend to thin and lose hydration with age, not thicken.
D. The force of isometric contraction typically decreases with aging due to muscle weakness and decreased muscle mass.
Correct Answer is B
Explanation
A. Contact precautions are not necessary for hepatitis C unless there is visible contamination of the environment with blood.
B. Hepatitis C is spread primarily through blood-to-blood contact, so the nurse should implement standard precautions, which include wearing gloves and other protective barriers as necessary.
C. Droplet precautions are used for infections spread by respiratory droplets, not for hepatitis C.
D. Airborne precautions are used for diseases that spread through airborne particles, such as tuberculosis.
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