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 B

Explanation

A. An abrasion is a superficial wound caused by scraping or rubbing and does not involve the full thickness of the skin.

B. A full-thickness wound with jagged edges and visible muscle tissue is a laceration. Lacerations are typically caused by trauma and result in irregular edges and deeper tissue damage.

C. A puncture wound is caused by a sharp object penetrating the skin, often with a small opening.

D. A contusion is a bruise caused by blunt force trauma that results in damage to underlying tissues but does not involve a break in the skin.

A. Wears sterile gloves when moving sterile items on the sterile field. B. Positions the wrapped package on the bedside table so the outer flap is away from her. C. Holds gauze packages 15 cm (6 in) above the sterile field. D. Holds a bottle of solution with the label away from the palm of the hand.

Correct Answer is C

Explanation

A. Wearing sterile gloves when moving sterile items is appropriate practice and should not be intervened with.

B. Positioning the wrapped package so the outer flap is away from the nurse is correct to prevent contamination when opening.

C. The nurse should avoid holding sterile items too far above the sterile field to prevent contamination from falling or being exposed to non-sterile areas. Items should be held as close as possible to the sterile field, typically no more than 2 inches (5 cm).

D. Holding the bottle of solution with the label away from the palm of the hand is proper to maintain sterility.

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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

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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