A patient presents to the Emergency Room with swollen legs and shortness of breath. He tells you that he has a history of heart failure which causes the fluid to build up m his legs and lungs. When you listen to his lung sounds you are most likely to hear which type of breathing sounds?
Rales
Crackles
Rhonchi
Stridor
The Correct Answer is B
Crackles, also known as rales, are discontinuous sounds that are typically heard during inspiration in patients with heart failure. These sounds are produced by the sudden opening of small airways and alveoli that are filled with fluid or collapsed due to pulmonary congestion. The sound can be described as similar to the sound of rubbing hair between fingers or the sound of Velcro being pulled apart.
Rhonchi are continuous, low-pitched sounds that are typically heard during expiration and are caused by the movement of air through narrowed airways, such as in patients with chronic obstructive pulmonary disease (COPD). Stridor is a high-pitched, continuous sound that is typically heard during inspiration and indicates upper airway obstruction, which can be life-threatening. Neither rhonchi nor stridor are typically heard in patients with heart failure.
Therefore, based on the patient's history and symptoms, the most likely type of breathing sound to be heard on auscultation is crackles/rales.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Explanation: In clients with COPD, the secretions tend to be thick and sticky, which makes it difficult to cough up and clear the airway. To promote respiratory hygiene in this situation, the nurse should recommend increasing fluid intake. Adequate hydration helps to thin the secretions, making them easier to expectorate. The client should aim to drink at least 8-10 glasses of water or other fluids per day unless there is a medical reason not to do so.
Decreasing fluid intake (option a) would make the secretions even thicker and more difficult to clear. Taking Tylenol for secretions (option b) is not a recommended intervention as Tylenol is not indicated for thinning of secretions. Range-of-motion exercises (option c) are important to prevent complications such as pneumonia, but they are not directly related to promoting respiratory hygiene in this situation.
Correct Answer is B
Explanation
Crackles, also known as rales, are discontinuous sounds that are typically heard during inspiration in patients with heart failure. These sounds are produced by the sudden opening of small airways and alveoli that are filled with fluid or collapsed due to pulmonary congestion. The sound can be described as similar to the sound of rubbing hair between fingers or the sound of Velcro being pulled apart.
Rhonchi are continuous, low-pitched sounds that are typically heard during expiration and are caused by the movement of air through narrowed airways, such as in patients with chronic obstructive pulmonary disease (COPD). Stridor is a high-pitched, continuous sound that is typically heard during inspiration and indicates upper airway obstruction, which can be life-threatening. Neither rhonchi nor stridor are typically heard in patients with heart failure.
Therefore, based on the patient's history and symptoms, the most likely type of breathing sound to be heard on auscultation is crackles/rales.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today