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

Answer and Explanation

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.

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Correct Answer is A

Explanation

The client's greenish-yellow sputum with a musty odor may indicate an infection, such as pneumonia or bronchitis, which can aﬀect the client's lung function. By auscultating bilateral breath sounds, the nurse can assess for the presence of abnormal lung sounds, such as crackles or wheezing, which may indicate further respiratory compromise.

While obtaining a blood culture for tuberculosis (option b) may be appropriate in certain circumstances, the client's sputum color and odor do not necessarily indicate tuberculosis as the cause of their respiratory symptoms.

Requesting pulmonary function studies (option c) may also be beneficial in assessing the client's lung function, but this is not the priority assessment in this situation.

Finally, while documenting the findings (option d) is an important aspect of nursing care, it is not the priority action when the client is presenting with signs of compromised lung function.

A. Chart the reading at 91%, this is normal for a COPD patient. B. Place a non-rebreather on the patient with high ﬂow oxygen. C. Call the doctor if the patient is declining. D. Sit the patient up and have them breathe deep.

Correct Answer is D

Explanation

Sitting the patient up and encouraging deep breathing can help improve oxygenation and increase the pulse oximetry reading. This is a non-invasive intervention that can be implemented immediately to help improve the patient’s oxygen levels.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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