A nurse is auscultating the lungs of a client who has pleurisy. Which of the following adventitious breath sounds should the nurse expect to hear?

Popping sounds

Loud, gating sounds

Snoring sounds

Squeaky, musical sounds

Answer and Explanation

The Correct Answer is B

A. Popping sounds, also known as crackles, are typically associated with fluid in the alveoli, often seen in conditions like pneumonia or heart failure, not pleurisy.

B. Loud, grating sounds, known as pleural friction rub, are characteristic of pleurisy. This sound is produced by the inflamed pleural surfaces rubbing together during respiration.

C. Snoring sounds, or rhonchi, are usually heard in conditions involving airway obstruction by mucus, such as bronchitis, rather than pleurisy.

D. Squeaky, musical sounds, or wheezing, are associated with airway narrowing, such as in asthma or chronic obstructive pulmonary disease (COPD), and are not typically heard in pleurisy.

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Correct Answer is A

Explanation

A. Auscultating for a bruit at the site of an AV graft is the most appropriate method to assess its patency. A bruit is a sound made by turbulent blood flow, indicating that the graft is functioning.

B. Measuring blood pressure in both arms does not specifically assess the patency of the graft and could potentially harm the graft if measured in the affected arm.

C. Auscultating the antecubital fossa using a Doppler is not a standard practice for assessing AV graft patency; instead, a stethoscope is used directly over the graft site.

D. Checking the brachial and radial pulses does not assess the graft directly. Although pulse presence is important, it does not provide information about the graft’s patency.

A. Provide assistance to bathroom. B. Increase fluids. C. Perform a bladder scan. D. Insert a straight catheter.

Correct Answer is C

Explanation

A. Assisting the client to the bathroom might be helpful, but it is not the first action the nurse should take since the client hasn't voided for an extended period.

B. Increasing fluids may be beneficial but does not address the immediate concern of whether there is a problem with urinary retention.

C. Performing a bladder scan is the first action to determine if there is urine retention in the bladder. This information is crucial before deciding on further interventions, such as catheterization.

D. Inserting a straight catheter may be necessary if significant urinary retention is confirmed, but it should not be the first action without knowing the bladder's status.

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A nurse is auscultating the lungs of a client who has pleurisy. Which of the following adventitious breath sounds should the nurse expect to hear?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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