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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Cryoprecipitate is indicated for low fibrinogen or clotting factor issues, but the client’s primary issue
here is anemia and thrombocytopenia.
B. FFP is used to replace clotting factors. While it could be considered in certain situations, in this case, the primary concern is the severe anemia and thrombocytopenia.
C. This is the most appropriate choice, as the patient has low hemoglobin (anemia) and a very low platelet count, both of which require packed red blood cells and platelets.
D. This combination is typically used for clotting factor issues, not anemia and thrombocytopenia.
Correct Answer is A
Explanation
A. A decreased D-dimer level is a positive outcome, as D-dimer is elevated in DIC due to the formation of clots and the breakdown of fibrin. Lower levels indicate less clot formation and better control of the condition.
B. Fibrinogen levels are typically low in DIC due to consumption of clotting factors. Elevated fibrinogen in this case would be a negative indicator, suggesting that clotting is not resolving.
C. A decreased platelet count is a hallmark of DIC and indicates ongoing consumption of platelets due to widespread clotting. A decrease would not be a positive outcome.
D. A prolonged PT is another indicator of DIC, suggesting impaired clotting function. This is not a positive outcome.
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