A nurse is collecting data from a client who is having an acute asthma exacerbation.
When auscultating the client's chest, the nurse should expect to hear which of the following sounds?

Fine rales.

Rhonchi.

Expiratory wheeze.

Pleural friction rub.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Fine rales Fine rales, also known as crackles, are typically associated with conditions like pulmonary edema, pneumonia, or interstitial lung diseases. These sounds are often described as "crackling" or "popping" and are heard during inspiration. In an acute asthma exacerbation, expiratory wheezing is more characteristic than fine rales.

Choice B rationale:

Rhonchi Rhonchi are continuous, low-pitched sounds that can be heard in conditions like chronic obstructive pulmonary disease (COPD) or bronchitis. They are typically present during both inspiration and expiration. In an acute asthma exacerbation, you would expect to hear wheezing during expiration, which is different from the characteristics of rhonchi.

Choice D rationale:

Pleural friction rub Pleural friction rub is a grating, leathery sound caused by the inflamed pleura rubbing against each other. It is typically heard during both inspiration and expiration and is associated with conditions like pleuritis or pleurisy. It is not commonly associated with acute asthma exacerbation. Now, let's move on to the next question.

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Correct Answer is A

Explanation

Choice A rationale:

The nurse should instruct the client to consume foods rich in potassium because furosemide, a loop diuretic, can lead to potassium depletion. By consuming potassium-rich foods, the client can help maintain proper electrolyte balance. Common potassium-rich foods include bananas, oranges, potatoes, and leafy greens. It is crucial to prevent hypokalemia, as it can result in adverse effects such as cardiac dysrhythmias and muscle weakness.

Choice B rationale:

Taking furosemide at bedtime is not necessary, and it is not a standard instruction. Furosemide is usually taken in the morning to avoid nocturia, as it increases urine output. This option does not address the primary concern of managing pulmonary edema and the potential electrolyte imbalances associated with furosemide use.

Choice C rationale:

Taking aspirin for headaches is not relevant to the client's condition of pulmonary edema or the use of furosemide. This choice does not provide valuable guidance to the client and may lead to unnecessary medication use.

Choice D rationale:

Expecting swelling in the hands and feet is not an appropriate instruction for a client with pulmonary edema. The goal of furosemide therapy is to reduce edema and fluid retention, not to expect or tolerate swelling. This option does not contribute to the client's well-being and recovery.

A. Administer the medication with each meal. B. Have suction equipment at the bedside. C. Monitor the client for black, tarry stools. D. Initiate contact precautions.

Correct Answer is C

Explanation

The correct answer is choice C. Monitor the client for black, tarry stools.

Choice A rationale:

Administering clopidogrel with each meal is not necessary. Clopidogrel can be taken with or without food. The primary concern with clopidogrel is its potential to cause bleeding, so monitoring for signs of bleeding is more critical.

Choice B rationale:

Having suction equipment at the bedside is not specifically required for clients taking clopidogrel. This action is more relevant for clients at risk of airway obstruction or those undergoing procedures that might require suctioning.

Choice C rationale:

Monitoring the client for black, tarry stools is essential because it can indicate gastrointestinal bleeding, a known side effect of clopidogrel. This medication increases the risk of bleeding, so observing for signs of internal bleeding, such as melena (black, tarry stools), is crucial.

Choice D rationale:

Initiating contact precautions is not necessary for clients taking clopidogrel. Contact precautions are typically used to prevent the spread of infections, not for managing clients on antiplatelet therapy.

By understanding these rationales, the nurse can ensure the safe administration and monitoring of clopidogrel therapy.

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A nurse is collecting data from a client who is having an acute asthma exacerbation.When auscultating the client's chest, the nurse should expect to hear which of the following sounds?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing discharge teaching with a client who has pulmonary edema and is about to start taking furosemide.Which of the following instructions should the nurse include?

Correct Answer is A

Explanation

A nurse is caring for a client who has a prescription for clopidogrel. Which of the following actions should the nurse plan to take?

Correct Answer is C

Explanation

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A nurse is collecting data from a client who is having an acute asthma exacerbation.
When auscultating the client's chest, the nurse should expect to hear which of the following sounds?