During auscultation, the nurse hears fine rales in the patient's lower lobes bilaterally. Fine rales are described as
A sonorous wheeze upon inspiration.
Musical or whistling sounds with respirations.
Noisy, snoring sounds during respirations.
Sounding like hair being rubbed between the thumb and index fingers.
The Correct Answer is D
A: Sonorous wheezes are low-pitched sounds and do not describe fine rales.
B: Musical or whistling sounds typically describe wheezes which are continuous and not the discontinuous sound of rales.
C: Noisy, snoring sounds are characteristic of rhonchi, not rales.
D: Fine rales are high-pitched, brief, and discontinuous crackling sounds that are often likened to the sound of hair being rubbed between fingers, indicative of fluid in the small airways.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A: To accurately determine a pulse deficit, one nurse must listen to the apical pulse while another nurse palpates the radial pulse simultaneously to compare both pulse rates, necessitating a second person.
B: Counting the apical pulse is a part of the process but would follow after ensuring another nurse is available to check the radial pulse at the same time.
C: This action relates to checking a pulse rate generally but does not specify the need for simultaneous comparison with the apical pulse.
D: Calculation of the difference is the final step after both pulses have been counted simultaneously.
Correct Answer is D
Explanation
A. Decreased plasma volume might cause overall weak pulses but would unlikely cause an absent pulse specifically localized in one or more extremities. Decreased plasma volume generally affects circulation systemically, not selectively in certain limbs.
B. Problems with the heart's electrical conduction system primarily affect the rhythm and rate of the heart but do not directly cause absent pulses in extremities. These issues lead to irregular or abnormal heartbeats, not localized absence of pulses.
C. Shock can result in weak or thready pulses due to poor blood flow, but shock alone would not typically cause a pulse to be completely absent in one extremity while present in others. Shock affects the circulatory system as a whole.
D. A blockage of blood flow is the most likely cause of an absent pulse in one or more extremities. This could be due to atherosclerosis, embolism, or thrombosis, which can obstruct blood flow in specific areas, leading to no detectable pulse in those extremities.
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