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. Emphasize four important points at each session. B. Have short teaching sessions. C. Refer to the client in the third person during the session. D. Use a passive voice to explain the information.

Correct Answer is B

Explanation

A. Emphasizing four important points is helpful, but it may be more effective to limit the number of points to ensure the client can focus on and remember key concepts.

B. Short teaching sessions are recommended for clients with low literacy levels because they are easier to understand and retain. Breaking down information into smaller, manageable segments can help prevent overwhelming the client.

C. Referring to the client in the third person may create distance and is not conducive to fostering a supportive, clear, and engaging learning environment.

D. Using passive voice can make the information less clear and harder for the client to understand. Active voice is generally more direct and effective in communication.

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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

A nurse is assessing a client's cranial nerves as part of a neurological examination. Which of the following actions should the nurse take to assess cranial nerve III?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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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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