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.

Answer and Explanation

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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Correct Answer is C

Explanation

A radial pulse is the pulse felt at the wrist, where the radial artery runs along the thumb side of the forearm. It is one of the most common sites for measuring a person's heart rate.
To measure a radial pulse, the examiner should place two or three fingers over the radial artery, just below the wrist crease, and apply gentle pressure until a pulsation is felt. The examiner should not use the thumb, as it has its own pulse and may interfere with the accuracy of the measurement. The examiner should count the number of beats for 15, 30, or 60 seconds, depending on the regularity and rate of the pulse.
In the picture, the unlicensed assistive personnel (UAP) is using the thumb to measure the radial pulse, which is incorrect. The practical nurse (PN) should demonstrate the correct pulse site to the UAP and explain why using the thumb is not appropriate. This will help to ensure that the UAP obtains an accurate and reliable pulse rate for the client.

Therefore, option C is the correct answer, while options A, B, and D are incorrect.

Option A is incorrect because instructing the UAP to report any abnormal findings does not address the error in technique.

Option B is incorrect because reminding the UAP to check the pulse volume does not address the error in technique.

Option D is incorrect because confirming the accuracy of the pulse rate obtained by the UAP does not address the error in technique.

A. Gather information regarding how long it will take for the children to arrive. B. Explain that the client will start to lose consciousness and the body systems will slow down. C. Offer to discuss the client's health status with each of the adult children. D. Reassure the spouse that the healthcare provider will notify when to call the children.

Correct Answer is B

Explanation

Choice B rationale:

Explaining that the client will start to lose consciousness and the body systems will slow down is the best response. This is a common pattern in the dying process, and it provides the wife with a clear and compassionate explanation of what to expect as her husband's death approaches.

Choice A rationale:

Gathering information regarding how long it will take for the children to arrive is important but does not address the immediate need for information on the dying process.

Choice C rationale:

Offering to discuss the client's health status with each of the adult children is a good approach for involving them in their father's care but does not provide the immediate information the wife is seeking.

Choice D rationale:

Reassuring the spouse that the healthcare provider will notify when to call the children does not offer information about the dying process itself, which is what the wife is interested in understanding.

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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]

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The practical nurse (PN) observes a newly hired unlicensed assistive personnel (UAP) who is counting a client's radial pulse as seen in the picture. Which action should the PN take?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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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]