The practical nurse (PN) is auscultating a client's lung sounds. Which description should the PN use to document this sound? (Please listen to the audio clip provided).
Audio: [Wheezing sound]
Wheeze.
Rhonchi.
Stridor.
Fine crackles.
The Correct Answer is A
Based on the provided audio clip, the sound heard is a high-pitched, continuous, musical sound. This sound is characteristic of wheezing, which is caused by the narrowing of the airways due to inflammation, bronchoconstriction, or the presence of mucus. Wheezing is commonly associated with conditions such as asthma, chronic obstructive pulmonary disease (COPD), or bronchitis.
Let's evaluate the other options:
b) Rhonchi: Rhonchi are low-pitched, coarse, ratling sounds that typically indicate the presence of mucus or fluid in the larger airways. Rhonchi are often heard in conditions such as pneumonia or bronchitis, but they are different from the high-pitched wheezing sound heard in the audio clip.
c) Stridor: Stridor is a high-pitched, harsh, and crowing sound that is heard during inspiration. It is often associated with upper airway obstruction, such as in cases of croup, epiglottitis, or a foreign body obstruction. The sound in the audio clip does not match the characteristics of stridor.
d) Fine crackles: Fine crackles are discontinuous, high-pitched, and brief sounds that are typically heard during inspiration. They are often described as "velcro-like" or "rice crispies" and are associated with conditions such as pulmonary fibrosis or congestive heart failure. The sound in the audio clip does not resemble fine crackles.
In summary, the sound in the provided audio clip is best described as wheezing, characterized by a high- pitched, continuous, musical sound. Therefore, the practical nurse (PN) should document this sound as "wheeze."
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The practical nurse (PN) should reteach the proper use of the spirometer when the client demonstrates blowing forcefully into the mouthpiece. The proper way to use an incentive spirometer is to sit upright, hold the spirometer upright, place your mouth around the mouthpiece, breathe out slowly, and then inhale slowly only through your mouth as deeply as you can. Blowing forcefully into the mouthpiece is not the correct way to use an incentive spirometer.
B. Exhaling slowly after two seconds: This is actually a correct action when using an incentive spirometer. The proper way to use an incentive spirometer is to exhale slowly before inhaling deeply.
C. Using a tight seal around the mouthpiece: This is also a correct action when using an incentive spirometer. It’s important to create a tight seal around the mouthpiece with your lips to ensure that you’re inhaling and exhaling only through your mouth.
D. Sitting upright during the treatment: This is another correct action when using an incentive spirometer. Sitting upright helps you to breathe more deeply and fully, which is the goal of using an incentive spirometer.
Correct Answer is A
Explanation
Worsening perineal pain after medication could indicate inadequate pain relief or a potential complication such as infection or hematoma. It is important to reassess the client to determine the cause of the increased pain and take appropriate action before transferring to the postpartum unit.
The other scenarios described in the options may also require attention, but they do not indicate an immediate need for reassessment before transfer:
B. A primigravida who passed a small clot when she sat up on the edge of the bed: Passing small clots is a normal part of the postpartum period, and it may not necessarily require immediate reassessment. However, the PN should monitor for any excessive or large clots and report any concerning findings.
C. A multigravida whose peri-pad is 1⁄2 saturated with lochia rubra after one hour: Lochia rubra is the normal discharge following childbirth, and some saturation of the peri-pad is expected.
However, the PN should continue to monitor the amount and consistency of the lochia and report any significant changes.
D. A multigravida complaining of strong afterbirth pains when breastfeeding: Afterbirth pains, also known as uterine cramps, are common during breastfeeding as the uterus contracts. While discomfort is expected, strong afterbirth pains should be assessed for severity and managed appropriately. The PN should provide comfort measures and assess if the pain is within the expected range or if it requires further evaluation.
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