The nurse hears short, rattling, high-pitched sounds in the lower lobes of a client with pneumonia. Which finding should the nurse document?

Stridor.

Pleural rub.

Wheezing.

Crackles.

Answer and Explanation

The Correct Answer is D

D. The short, rattling, high-pitched sounds heard in the lower lobes of the client with pneumonia are indicative of crackles. Crackles are abnormal respiratory sounds that occur when air moves through fluid or mucus in the small airways or alveoli.

A. Stridor refers to a high-pitched, wheezing sound that occurs during inspiration or expiration and is typically associated with upper airway obstruction, such as in conditions like croup or foreign body aspiration.

B. Pleural rub refers to a grating or rubbing sound heard on auscultation that occurs when inflamed pleural surfaces rub against each other during respiration. It is commonly heard in conditions such as pleurisy or pleural effusion.

C. Wheezing refers to a high-pitched, musical sound heard during expiration that is typically associated with narrowing or obstruction of the airways, as seen in conditions like asthma or chronic obstructive pulmonary disease (COPD).

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Correct Answer is C

Explanation

C. Urinary incontinence affects the moisture component of the Braden scale. Proper assessment and interventions are crucial to prevent skin breakdown.

A. A weakened cough effort is not directly related to pressure ulcer risk assessment, which is the purpose of the Braden Scale.

B. Bowel sounds are not included in the Braden Scale assessment criteria.

D. Ankle edema is not included as a factor in the Braden Scale assessment.

A. Empty the sample into the 24 hour container. B. Start collecting the specimen with the next void. C. Begin the collection the next day. D. Observe the sample for sediment

Correct Answer is B

Explanation

A. Emptying the sample into the 24-hour container would mix the previously voided urine with the new collection, leading to inaccurate results.

B. The nurse should discard the urine that was collected earlier and start the collection process anew with the next void. This ensures that the entire 24-hour urine output is collected accurately.

C. The collection can be started immediately with the next void, even if it's a few hours after the original start time.

D. Observing the sample for sediment does not address the need for a complete 24-hour collection.

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The nurse hears short, rattling, high-pitched sounds in the lower lobes of a client with pneumonia. Which finding should the nurse document?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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