A nurse is auscultating the breath sounds of a client who has congestive heart failure. When the client exhales, the nurse hears bubbling, popping like sounds. The nurse should document this as which of the following adventitious breath sounds?

Wheezes

Stridor

Rhonchi

Crackles

Answer and Explanation

The Correct Answer is D

A. Wheezes:

Wheezes are high-pitched, musical sounds that occur during inspiration or expiration and are often associated with narrowed airways, such as in conditions like asthma or chronic obstructive pulmonary disease (COPD).

B. Stridor:

Stridor is a high-pitched, crowing sound that is typically heard during inspiration and can be associated with upper airway obstruction, such as in croup or epiglottitis.

C. Rhonchi:

Rhonchi are low-pitched, snoring or rattling sounds that can occur during inspiration or expiration. They are often associated with the presence of mucus or other airway obstruction and can be heard in conditions like bronchitis or pneumonia.

D. Crackles:

Crackles are bubbling, popping sounds heard during inspiration or expiration. They can be further classified as fine or coarse. Fine crackles are often associated with conditions like pulmonary fibrosis, while coarse crackles can be heard in conditions like congestive heart failure or pneumonia.

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Correct Answer is A

Explanation

A. Check temperature and SPO2

When the nurse finds an adult patient's pulse rate to be 140 beats per minute, it is important to assess other vital signs, particularly temperature and oxygen saturation (SPO2). This helps gather additional information to understand the overall clinical picture and assess for potential underlying causes of the elevated heart rate.

B. Report the rate to the primary care provider:

Reporting the heart rate to the primary care provider may be necessary, but it should not be the immediate action. Assessing other vital signs first provides a more comprehensive understanding.

C. Check the pulse again in 2 hours:

Waiting for 2 hours to recheck the pulse is not appropriate when the heart rate is significantly elevated. Immediate action and further assessment are needed.

D. Record the information:

Recording the elevated heart rate is part of documentation, but it should be accompanied by a more comprehensive assessment of vital signs and potential contributing factors.

A. Regular deep respirations interspersed with periods of apnea B. A pattern of crescendo-decrescendo respirations followed by a period of apnea C. Patient breathing less than 10 breaths per minute D. Patient breathing shallow and more than 24 breaths per minute

Correct Answer is B

Explanation

A. Regular deep respirations interspersed with periods of apnea:

This describes periodic breathing, which is different from Cheyne-Stokes respirations. Periodic breathing consists of regular cycles of deep respirations followed by periods of apnea.

B. A pattern of crescendo-decrescendo respirations followed by a period of apnea

Cheyne-Stokes respirations are characterized by a pattern of crescendo-decrescendo respirations, meaning that the depth and rate of breathing gradually increase and then decrease. This is followed by a period of apnea, during which there is a temporary cessation of breathing. The cycle then repeats.

C. Patient breathing less than 10 breaths per minute:

This describes bradypnea, which is an abnormally slow respiratory rate. Cheyne-Stokes respirations involve rhythmic, cyclical changes in respiratory rate and depth.

D. Patient breathing shallow and more than 24 breaths per minute:

This describes tachypnea, which is an abnormally fast respiratory rate. Cheyne-Stokes respirations are characterized by a distinct pattern of alternating crescendo-decrescendo respirations followed by apnea.

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A nurse is auscultating the breath sounds of a client who has congestive heart failure. When the client exhales, the nurse hears bubbling, popping like sounds. The nurse should document this as which of the following adventitious breath sounds?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While taking an adult patient’s pulse, a nurse finds the rate to be 140 beats/min. What should the nurse do next?

Correct Answer is A

Explanation

The nurse notes documentation that a client is exhibiting Cheyne-Stokes respirations. On assessment, what finding would the nurse expect?

Correct Answer is B

Explanation

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