A nurse is documenting the findings of a physical examination on a client who has heart failure.
Which of the following terms should the nurse use to describe crackles heard in the lungs?
Wheezes
Rhonchi
Rales
Stridor
The Correct Answer is C
Rales
Rationale: Rales are fine, high-pitched crackling sounds heard in the lungs due to fluid accumulation or inflammation. They are commonly heard in clients who have heart failure, pneumonia, or pulmonary edema.
Incorrect options:
A) Wheezes - Wheezes are high-pitched musical sounds heard in the lungs due to narrowed airways. They are commonly heard in clients who have asthma, chronic obstructive pulmonary disease (COPD), or bronchitis.
B) Rhonchi - Rhonchi are low-pitched snoring sounds heard in the lungs due to secretions or mucus in the large airways. They are commonly heard in clients who have bronchitis, cystic fibrosis, or pneumonia.
D) Stridor - Stridor is a high-pitched crowing sound heard in the upper airway due to obstruction or inflammation. It is commonly heard in clients who have croup, epiglottitis, or foreign body aspiration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Respiratory depression
Rationale: Respiratory depression is a life-threatening complication of substance abuse, especially opioid overdose, that requires immediate intervention. The nurse should report this finding to the provider and prepare to administer naloxone, an opioid antagonist, as prescribed.
Incorrect options:
A) Dilated pupils - This is a common finding in clients who abuse stimulants, such as cocaine or methamphetamine, but it is not an emergency.
B) Slurred speech - This is a common finding in clients who abuse depressants, such as alcohol or benzodiazepines, but it is not an emergency.
C) Agitation and restlessness - This is a common finding in clients who abuse stimulants, such as cocaine or methamphetamine, but it is not an emergency.
Correct Answer is D
Explanation
"I think that I can drive myself home after the procedure."
Rationale: The client should be informed that they cannot drive themselves home after the procedure, as they will be under the influence of sedation and may experience drowsiness, impaired judgment, and delayed reaction time. The client should arrange for a responsible adult to accompany them home and stay with them until the effects of sedation wear off.
Incorrect options:
A) "I understand that I will be sedated during the procedure." - This is a correct statement, as sedation is usually administered during a colonoscopy to reduce discomfort and anxiety.
B) "I know that I have to drink a lot of clear liquids before the procedure." - This is a correct statement, as drinking clear liquids before the procedure helps to cleanse the bowel and improve visualization.
C) "I expect that I will have some abdominal cramps and gas after the procedure." - This is a correct statement, as abdominal cramps and gas are common after a colonoscopy due to air insufflation during the procedure. The client should be advised to ambulate and pass gas as tolerated to relieve these symptoms.
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