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
AB+ blood type is known as the universal recipient because individuals with this blood type have both A and B antigens on the surface of their red blood cells, as well as the Rh antigen. This means that they can receive blood from donors of any ABO blood type (A, B, AB, or O) and Rh factor (positive or negative) without experiencing a transfusion reaction.
Therefore, in the case of a patient who will be needing a blood transfusion, if the nurse knows that the patient's blood type is unknown, it is ideal to give them AB+ blood type as it is considered the safest option.
Correct Answer is B
Explanation
: A client with renal disease may have impaired kidney function, which can affect fluid balance in the body. Giving fluids too quickly or increasing the infusion rate too quickly can lead to fluid overload,
which can exacerbate the client's condition. It is important for the nurse to monitor the amount of fluid the client is receiving to ensure that the infusion rate is appropriate for the client's condition and to prevent fluid overload. Checking the intravenous rate every two days is not sufficient; the nurse should monitor the rate regularly and adjust it as necessary based on the client's response.
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