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 D

Explanation

A. The client attempted to climb over the side rails and fell:

This statement includes an interpretation of the client's actions. It's important to focus on factual information without making assumptions about the client's intentions or actions.

B. The client was restless and trying to get out of bed all evening:

Describing the client as restless and trying to get out of bed is a subjective interpretation of the client's behavior. Factual and objective observations are preferred when documenting incidents.

C. The presence of a bed alarm could have prevented the client from falling:

This statement includes an interpretation and a suggestion for prevention. While prevention strategies are important to consider, an incident report should primarily focus on describing what actually occurred rather than suggesting what could have prevented it.

D. The client was lying on the floor next to his bed:

This statement provides a clear and objective description of the situation without making assumptions or interpretations. It is important to document the actual events and the client's current condition.

Correct Answer is ["45"]

Explanation

To calculate the amount of potassium chloride (K-Dur) solution to administer, we need to use the following formula:

mL to administer = ordered dose (mEq) / available dose (mEq/mL) x mL

Plugging in the values from the question, we get:

mL to administer = 60 mEq / (20 mEq / 15 mL) x 15 mL

Simplifying the equation, we get:

mL to administer = 60 mEq x 15 mL / 20 mEq

mL to administer = 45 mL

Therefore, the nurse should administer 45 mL of potassium chloride (K-Dur) solution to the patient.

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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

A nurse is filling out an incident report after finding a client lying on the floor. Which of the following information should the nurse include?

Correct Answer is D

Explanation

Ordered: Potassium chloride (K-Dur) 60 mEq Available: Potassium chloride (K-Dur) 20 mEq/15 mL Administer: _____mL

Correct Answer is ["45"]

Explanation

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