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 D
Explanation
A. Listening for all possible sounds at a time at each specified area: This approach does not allow for specific localization of different heart sounds and murmurs, making it difficult to accurately assess the heart's condition.
B. Listening to the sounds at the aortic, tricuspid, pulmonic, and mitral areas: This option is close but lacks the systematic approach of method D. Listening at specific anatomical locations (aortic, tricuspid, pulmonic, mitral) is important, but the Z pattern allows for thorough coverage and precise localization of any abnormal sounds.
C. Listening to the sounds only at the site where the apical pulse is felt to be the strongest: This method does not cover all the important auscultation sites on the heart and may miss significant findings.
D. Listening by inching the stethoscope in a rough Z pattern, from the base of the heart across and down, then over to the apex: This technique involves a systematic approach where the nurse listens at specific locations in a structured manner, ensuring comprehensive coverage of the heart sounds and murmurs.
Correct Answer is A
Explanation
A. Maxillary sinusitis:
Explanation: The client's symptoms of facial pain, fever, malaise, swollen turbinates, purulent nasal discharge, and dull, throbbing pain in the cheeks and teeth on the right side, especially when palpated, are indicative of maxillary sinusitis. Maxillary sinusitis refers to the inflammation of the maxillary sinuses, which are located in the cheek area. The symptoms described align with a bacterial infection in this sinus.
B. Nasal polyps:
Explanation: Nasal polyps are soft, noncancerous growths on the lining of the nasal passages or sinuses. While they can cause nasal congestion and a runny nose, they do not typically present with the specific symptoms mentioned in the scenario, such as facial pain, fever, and purulent discharge.
C. Frontal sinusitis:
Explanation: Frontal sinusitis involves inflammation of the frontal sinuses located in the forehead area. Symptoms may include forehead pain, headache, and nasal discharge. However, the described symptoms in the scenario (dull, throbbing pain in the cheeks and teeth on the right side) are more characteristic of maxillary sinusitis.
D. Posterior epistaxis:
Explanation: Posterior epistaxis refers to a nosebleed that originates from the back of the nose, often due to bleeding from the sphenopalatine artery. While nosebleeds can cause blood drainage into the throat and result in a metallic taste, the other symptoms described in the scenario, such as facial pain, fever, and purulent discharge, are not indicative of posterior epistaxis.
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