Upon assessment of the client's lungs, the nurse hears continuous, high-pitched, musical sounds. This should be documented as:

fine crackles

wheezes

rhonchi

vesicular sounds

Answer and Explanation

The Correct Answer is B

A.   Fine crackles - Fine crackles are short, popping sounds usually heard during inspiration, indicative of fluid in the lungs.
B.   Wheezes - Wheezes are continuous, high-pitched musical sounds caused by narrowed airways, often seen in asthma, bronchitis, or other respiratory conditions.
C.   Rhonchi - Rhonchi are low-pitched, rattling sounds that occur when air flows through thick mucus or secretions in the larger airways.
D.   Vesicular sounds - Vesicular breath sounds are normal lung sounds heard over most lung fields during inspiration. They are not continuous and high-pitched.

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Correct Answer is D

Explanation

A. This type of AV block is characterized by a progressively lengthening PR interval until a QRS complex is dropped (a blocked beat). A PR interval of 0.28 seconds could be seen in 2nd degree Mobitz I (Wenckebach), not Mobitz II, which has a more irregular pattern of dropped beats
B. Atrial flutter: Atrial flutter is a type of arrhythmia characterized by rapid atrial rates (typically around 250-350 beats per minute) with a sawtooth pattern of P-waves. It does not relate to the PR interval, but rather the atrial rhythm.
C. Sinus bradycardia: Sinus bradycardia is characterized by a slower-than-normal heart rate (less than 60 beats per minute), but this does not affect the PR interval directly. A normal PR interval (0.12-0.20 seconds) can still be seen in sinus bradycardia, so the prolonged PR interval in this case makes sinus bradycardia less likely.
D. 1st degree AV block: In 1st degree AV block, the PR interval is consistently prolonged, usually more than 0.20 seconds, but it is still a constant, non-variable delay in the conduction between the atria and ventricles. A PR interval of 0.28 seconds (which is longer than normal but consistent) is characteristic of a first-degree AV block, making it the correct answer.

A. Perform a 12 lead EKG and request an order for bumetanide 0.5 mg IV B. Administer pantoprazole sodium 40 mg by mouth to decrease GI distress C. Administer carvedilol 10 mg by mouth and reassess in 30 minutes D. Complete the remainder of the assessment and continue to monitor

Correct Answer is D

Explanation

A. The 12-lead EKG might be unnecessary right now, especially since the client has no other alarming symptoms. Bumetanide is also not indicated for nausea or tachycardia in this scenario.
B. There is no clear indication that the nausea is related to acid reflux or GI distress that would justify pantoprazole.
C. The tachycardia could be physiological, and treating it with a beta-blocker is unnecessary unless there is a more concerning underlying cause (like heart failure or ischemia). The priority here is not pharmacological intervention but monitoring the client's overall condition.
D. This action allows for appropriate monitoring of the client's condition. Sinus tachycardia may resolve on its own without intervention, and the client doesn't exhibit severe symptoms requiring immediate pharmacologic treatment.

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Upon assessment of the client's lungs, the nurse hears continuous, high-pitched, musical sounds. This should be documented as:

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Naxlex Comprehensive Predictor Exams

The nurse notes that the client's rhythm strip indicates a PR-interval of 0.28 seconds. What is the nurse's analysis of this problem?

Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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