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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. The patient's spouse reporting experiencing marital issues is a perfect example of secondary information as it comes from someone other than the patient and might affect the patient's care or emotional well-being indirectly.
B. The patient reports a history of chest pain, is an example of primary information. This is because the patient directly reports the symptoms of their health condition.
C. The patient complaining of chronic constipation is an example of primary information. This is because the patient is directly reporting their own health condition.

D. The patient verbalizes anxiety about hospitalization is also primary information, directly provided by the patient concerning their feelings about the current care environment.

A. The patient's daughter appears anxious about the patient's hospitalization. B. The patient reports a history of chronic obstructive pulmonary disease. C. The patient's spouse reports the patient has difficulty sleeping. D. The patient's caregiver complains of feeling overwhelmed.

Correct Answer is B

Explanation

A: The daughter's anxiety is secondary information and not directly related to the patient's health status.
B: The patient's self-reported medical history is primary data as it comes directly from the patient and provides essential information for the assessment.
C: The spouse's report of the patient's difficulty sleeping is secondary information and not directly observed or reported by the patient.
D: The caregiver's complaint is secondary information and does not provide direct insight into the patient's health status.

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During auscultation, the nurse hears fine rales in the patient's lower lobes bilaterally. Fine rales are described as

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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