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 B
Explanation
A. Contact precautions are used for infections that are spread through direct contact with contaminated surfaces or items.
B. Droplet precautions are used for infections spread through respiratory droplets, such as influenza.
C. Protective isolation is used for clients with weakened immune systems, but TB requires airborne precautions, not protective isolation.
D. Tuberculosis (TB) is transmitted via airborne particles, so the nurse should initiate airborne precautions, including the use of an N95 respirator, negative pressure rooms, and other measures to prevent the spread of TB.
Correct Answer is D
Explanation
A. Quaternary prevention focuses on preventing over-medicalization or unnecessary interventions in health care.
B. Tertiary prevention aims to reduce the impact of an already established disease, such as rehabilitation.
C. Secondary prevention focuses on early detection of disease to prevent progression, such as through screenings.
D. Primary prevention aims to prevent the onset of disease or injury before it occurs. Immunizations and water fluoridation are both measures that help prevent disease in the general population before it starts.
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