A nurse is auscultating the lungs of a sleeping client and hears short, popping, crackling breath sounds that stop after a few breaths. How should the nurse document these breath sounds in the client's medical record?

Atelectatic crackles that do not have a pathologic cause

Fine crackles that may be a sign of impending pneumonia

Vesicular breath sounds

Fine wheezes

Answer and Explanation

The Correct Answer is A

A) Atelectatic crackles that do not have a pathologic cause:
Atelectatic crackles are short, popping, crackling sounds heard during auscultation, typically occurring at the end of inspiration. These crackles are often heard in the bases of the lungs, particularly when the client is in a supine position, and are not associated with any pathological condition. Atelectatic crackles are a normal finding, especially in a sleeping or newly awakened client, as they result from the temporary collapse of small airways that quickly re-expand. Since they disappear after a few breaths and are not indicative of disease, they should be documented as atelectatic crackles without a pathological cause.

B) Fine crackles that may be a sign of impending pneumonia:
Fine crackles are high-pitched, popping sounds that are often heard during inspiration, especially at the lung bases. They are commonly associated with conditions like pneumonia, heart failure, or pulmonary fibrosis. However, in this case, the crackles heard stopped after a few breaths, which is characteristic of atelectatic crackles rather than fine crackles associated with pathological conditions. Fine crackles that last and occur consistently may suggest pathology, but in this scenario, the transient nature of the sounds points to atelectatic crackles, not pneumonia.

C) Vesicular breath sounds:
Vesicular breath sounds are normal lung sounds heard over the peripheral lung fields, characterized by a soft, low-pitched sound during inspiration, with a shorter expiration. These sounds are different from crackles, which are brief, popping sounds. Vesicular breath sounds do not refer to abnormal or adventitious sounds, such as the crackles heard in this client. Therefore, the nurse should not document the breath sounds as vesicular.

D) Fine wheezes:
Wheezes are continuous musical sounds produced by the narrowing of the airways, typically heard during exhalation. They are usually caused by conditions like asthma, chronic obstructive pulmonary disease (COPD), or bronchitis. The crackling sounds described in the question are not wheezes, as they are short, popping sounds rather than musical, continuous sounds. The transient nature of the sounds makes them more consistent with atelectatic crackles, not wheezes.

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Correct Answer is D

Explanation

A) The presence of cerumen in the ear canal:
This is incorrect. The presence of cerumen (earwax) in the ear canal is not inherently abnormal. In fact, cerumen is a natural substance produced by the body to protect and clean the ear canal. While excessive buildup can lead to blockages or hearing impairment, some amount of cerumen is normal and does not indicate an abnormal finding.

B) A shiny, pearly white color tympanic membrane:
This is incorrect. A shiny, pearly white tympanic membrane is a normal finding. This color and appearance indicate a healthy, intact eardrum. The tympanic membrane should be translucent with a smooth surface and this typical pearly appearance in a healthy ear.

C) A clear presence of a cone of light:
This is incorrect. The cone of light is a normal finding during otoscopic examination. It is a reflection of the otoscope light off the tympanic membrane and should be visible in the anterior-inferior quadrant of the tympanic membrane. The presence of the cone of light suggests that the eardrum is intact and in a normal position.

D) A yellow or amber color to the tympanic membrane:
This is the correct answer. A yellow or amber color of the tympanic membrane suggests the presence of fluid behind the eardrum, which may indicate an ear infection or otitis media. This color change is considered abnormal and should prompt further investigation, as it can be a sign of inflammation, infection, or the accumulation of fluid in the middle ear.

A. Client's oral temperature is 38.40 C (101.2° F). B. Client reports the rash on their back is itchy. C. Client reports nausea following, administration of pain medication. D. Client has a vesicular rash on their upper back. E. Client reports dull, aching pain in lower right call.

Correct Answer is ["B","C","E"]

Explanation

A) Client's oral temperature is 38.4°C (101.2°F):
This is objective data, as it is a measurable, observable finding obtained through direct assessment (in this case, using a thermometer). Objective data are facts or measurements that can be verified or observed by the healthcare provider.

B) Client reports the rash on their back is itchy:
This is subjective data, as it is based on the client's personal experience and report. The feeling of itchiness cannot be directly measured or observed by the nurse; it is something the client experiences and describes. Subjective data include symptoms, sensations, or feelings reported by the client.

C) Client reports nausea following administration of pain medication:
This is subjective data. Nausea is a symptom that the client reports experiencing, which cannot be objectively measured or directly observed by the nurse. It is based on the client's perception and report, making it subjective.

D) Client has a vesicular rash on their upper back:
This is objective data. The rash is something the nurse can observe and describe. Objective data include observable facts, such as physical exam findings, lab results, or diagnostic test results.

E) Client reports dull, aching pain in lower right calf:
This is subjective data, as pain is a sensation that the client experiences and describes. The intensity, location, and type of pain (dull, aching) are subjective experiences that only the client can report.

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A nurse is auscultating the lungs of a sleeping client and hears short, popping, crackling breath sounds that stop after a few breaths. How should the nurse document these breath sounds in the client's medical record?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse examines a client's auditory canal and tympanic membrane with an otoscope. The nurse should recognize that which of the following is considered an abnormal finding?

Correct Answer is D

Explanation

A nurse is documenting assessment findings on a client. Which of the following entries should the nurse identify as subjective data? (Select All that Apply.)

Correct Answer is ["B","C","E"]

Explanation

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