When auscultating a patient's lungs, a nurse hears an audible, high-pitched crowing sound. The nurse identifies this sound as
Rales
Stridor
wheezes
Rhonchi
The Correct Answer is B
A: Rales are described as fine crackling sounds, not high-pitched crowing.
B: Stridor is a high-pitched, wheezing sound heard primarily during inhalation and is often caused by an obstruction in the upper airway.
C: Wheezes are typically associated with asthma and are musical in nature, occurring mostly during exhalation.
D: Rhonchi are low-pitched sounds that resemble snoring and are caused by obstructions in the larger airways.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A: The daughter's anxiety is secondary information and not directly related to the patient's health status.
B: The patient's self-reported medical history is primary data as it comes directly from the patient and provides essential information for the assessment.
C: The spouse's report of the patient's difficulty sleeping is secondary information and not directly observed or reported by the patient.
D: The caregiver's complaint is secondary information and does not provide direct insight into the patient's health status.
Correct Answer is A
Explanation
A: To accurately determine a pulse deficit, one nurse must listen to the apical pulse while another nurse palpates the radial pulse simultaneously to compare both pulse rates, necessitating a second person.
B: Counting the apical pulse is a part of the process but would follow after ensuring another nurse is available to check the radial pulse at the same time.
C: This action relates to checking a pulse rate generally but does not specify the need for simultaneous comparison with the apical pulse.
D: Calculation of the difference is the final step after both pulses have been counted simultaneously.
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