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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale: Tuberculosis treatment with rifampin typically lasts 6 to 9 months. Lifelong therapy is not required for TB, and unnecessary prolonged use increases the risk of drug resistance and hepatotoxicity.
Choice B rationale: Rifampin induces liver enzymes that accelerate the metabolism of oral contraceptives, making them less effective. It does not cause amenorrhea, but it necessitates the use of non-hormonal backup contraception.
Choice C rationale: Rifampin causes a harmless reddish-orange discoloration of urine, sweat, tears, and saliva. This can permanently stain soft contact lenses, so clients are advised to wear eyeglasses during the treatment course.
Choice D rationale: A yellow tint to the skin or sclera indicates jaundice, which is a sign of hepatotoxicity. This is a serious adverse effect rather than an expected reaction and must be reported immediately.
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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