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. Wet-to-dry gauze dressings are typically used for more severe wounds, particularly for debridement, and are not appropriate for a stage I pressure ulcer.

B. A transparent dressing is appropriate for a stage I pressure ulcer because it provides a barrier to moisture while allowing for continuous observation of the area without disturbing the skin.

C. Hydrogel dressings are typically used for more complex wounds to hydrate and provide a moist healing environment but are not necessary for a stage I ulcer.

D. Alginate dressings are used for heavily exudating wounds and would not be appropriate for a stage I pressure ulcer.

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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

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Correct Answer is B

Explanation

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