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."
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Heart rate of 90 beats per minute with premature ventricular contractions (PVCs) noted on telemetry: This finding indicates an abnormality in the heart's electrical conduction system. PVCs are extra, abnormal heartbeats that originate in the ventricles. They can sometimes be benign, but they can also be associated with underlying heart conditions or electrolyte imbalances. Since the client is experiencing dizziness and tingling, which could be related to cardiac function, it is important to report this finding to the healthcare provider for further evaluation and appropriate management.
Incorrect:
A. Regular heart rate of 100 beats per minute on telemetry: This finding describes a heart rate within the normal range (60-100 beats per minute for adults). It does not indicate any immediate concerns or abnormalities that would require reporting to the healthcare provider in this context.
B. Hypoactive bowel sounds on assessment: Following a small bowel resection, it is common for bowel sounds to be temporarily reduced or absent due to the surgical manipulation and the bowel's response to anesthesia. Hypoactive bowel sounds alone do not directly relate to the client's reported symptoms of dizziness and tingling in digits, nor do they suggest an immediate need for reporting to the healthcare provider.
D. Hyperactive bowel sounds on assessment: Hyperactive bowel sounds, characterized by increased loudness and frequency, can occur due to conditions such as gastroenteritis or bowel obstruction. However, in the context of a client who has undergone a small bowel resection and is on NPO status, hyperactive bowel sounds would not be expected and may indicate a potential complication. While it is important to monitor and document this finding, it is not directly related to the client's reported symptoms and does not require immediate reporting to the healthcare provider in this scenario.
Correct Answer is A
Explanation
This is the correct answer, as it reflects the nurse's assessment of the injury and the appropriate action to take. The nurse should consider the mother's report of pain as a valid indicator of the severity of the injury, and should not dismiss or minimize it. The nurse should also observe the boy's arm and shoulder for any signs of fracture, dislocation, swelling, bruising, or deformity, and ask him to rate his pain on a scale of 0 to 10. The nurse should then decide whether to refer the boy to a physician or an emergency department for further evaluation and treatment.
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