The nurse is auscultating the lungs of an adult client. The nurse hears low-pitched, soft breath sounds over the posterior lower lobes and inspiration that is longer than expiration. The nurse recognizes that these breath sounds are:
Bronchovesicular breath sounds and normal in that location.
Normally auscultated over the trachea.
Vesicular breath sounds and normal in that location.
Bronchial breath sounds and normal in that location
The Correct Answer is C
A. Bronchovesicular breath sounds and normal in that location:
Bronchovesicular breath sounds are medium-pitched sounds heard over the major bronchi and are usually equal on inspiration and expiration. They are typically heard in the 1st and 2nd intercostal spaces anteriorly and between the scapulae posteriorly. While they might be normal in certain locations, hearing them over peripheral lung fields might indicate an abnormality.
B. Normally auscultated over the trachea:
This statement doesn't specify a particular type of breath sound. Tracheal breath sounds are harsh and relatively high-pitched, heard directly over the trachea. They are normal over the trachea but are not normally heard in the lung periphery.
C. Vesicular breath sounds and normal in that location:
Vesicular breath sounds are low-pitched, soft sounds heard over most of the lungs during inspiration. They are longer on inspiration than expiration and are considered normal breath sounds heard in the peripheral lung fields. Hearing vesicular sounds in the posterior lower lobes is typical and indicates normal lung function.
D. Bronchial breath sounds and normal in that location:
Bronchial breath sounds are high-pitched and loud, heard primarily over the trachea and larynx. If heard in the peripheral lung fields, especially in the lower lobes, it can suggest an abnormality such as consolidation or compression of lung tissue.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. The best time to perform a BSE is 4 to 7 days after the first day of the menstrual period:
This statement is correct. Performing BSE a few days after the menstrual period ensures that the breasts are less likely to be swollen or tender, which can make it easier to detect any unusual changes.
B. If she suspects that she is pregnant, then the woman should not perform a BSE until her baby is born:
This statement is incorrect. Pregnant women can still perform breast self-examinations. In fact, it's important for pregnant women to be aware of any changes in their breasts.
C. The best time to perform BSE is in the middle of the menstrual cycle:
This statement is not as accurate as the first choice. While it's true that performing BSE a few days after the menstrual period can be easier due to reduced breast tenderness, it doesn't necessarily mean the middle of the menstrual cycle for every woman. The timing can vary based on an individual's menstrual cycle.
D. The woman needs to perform BSE only bimonthly unless she has fibrocystic breast tissue:
This statement is incorrect. Regular monthly breast self-examinations are recommended for all women, regardless of whether they have fibrocystic breast tissue or not. Detecting changes early is crucial for breast health.
Correct Answer is A
Explanation
A. When part of the lung is obstructed or collapsed: This statement is accurate. Unequal chest expansion can occur when part of the lung is obstructed or collapsed, preventing the affected area from expanding normally during inhalation.
B. When bulging of the intercostal spaces is present: This statement is not accurate. Unequal chest expansion typically refers to decreased expansion on one side, not bulging of intercostal spaces.
C. In an obese patient: This statement is not accurate. Obesity can affect breathing patterns and lung function, but it is not the primary cause of unequal chest expansion.
D. When accessory muscles are used to augment respiratory effort: This statement is not accurate. The use of accessory muscles to augment respiratory effort can be a sign of respiratory distress, but it doesn't directly cause unequal chest expansion. Unequal expansion is more indicative of specific lung conditions or issues with lung mechanics.
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