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 B, A, C, D
Explanation
The correct sequence for the interventions when caring for a client with a tracheostomy tube, after donning sterile gloves, is as follows:
Hyperoxygenate with a bag valve mask (BVM) using a nondominant hand. Insert sterile suction catheter in tracheostomy tube.
Activate suction by covering the catheter opening. Withdraw and rotate the catheter while suction is applied.
The first step is to hyperoxygenate the client using a bag valve mask (BVM) with the nondominant hand. This helps to ensure that the client receives adequate oxygenation during the suctioning procedure.
Next, the sterile suction catheter is inserted into the tracheostomy tube. The catheter is carefully advanced until resistance is met, ensuring it does not force its way in.
After the catheter is inserted, the suction is activated by covering the catheter opening. This creates negative pressure and allows for the removal of secretions.
Finally, the catheter is withdrawn and rotated while suction is applied. This helps to thoroughly suction the secretions from the tracheostomy tube.
Correct Answer is B
Explanation
Bathing a bedfast client with the bed in a high position poses a potential risk to the client's safety. Lowering the bed to a safe height is important to prevent falls and injuries during the bathing procedure. The PN should promptly intervene and instruct the UAP to lower the bed to an appropriate level before continuing with the bathing process.
A. While remaining in the room to supervise the UAP is important, it should be done after ensuring the client's safety by lowering the bed. If the bed is not lowered, the risk of injury remains, and the PN should take immediate action to address the safety concern.
C. Determining if the UAP would like assistance is a valid consideration, but it should be secondary to addressing the safety issue of the bed height. Once the bed is lowered, the PN can assess if additional assistance is required and provide support accordingly.
D. Assuming care of the client immediately may be necessary if the client is in immediate danger or experiencing an urgent medical situation. However, in this case, the primary concern is addressing the safety issue related to the bed height, and the PN can address this by instructing the UAP to lower the bed.
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