When auscultating over the apex of the client's lung field, what breath sound should the nurse expect to hear?
Bronchovesicular
Vesicular
Bronchial
Crackles
The Correct Answer is B
B. Heard over most of the lung fields, except for the major bronchi and the trachea.
Low intensity and pitch, with a longer inspiratory phase than expiratory phase. They are softer and more breezy in quality. Vesicular breath sounds are heard over the peripheral lung fields, including the apex (top) of the lungs.
A. Heard over the major bronchi, which are near the sternum and between the scapulae. They are of intermediate intensity and pitch, with equal inspiration and expiration phases. They are typically heard in the 1st and 2nd intercostal spaces along the sternal border and between the scapulae.
C. Heard over the trachea and larynx.
Characteristics: High intensity and pitch, with a short inspiratory phase and a longer expiratory phase. They are louder and harsher in quality, resembling the sound of air blowing through a hollow pipe.
D. Crackles are abnormal breath sounds that can be fine or coarse.
Fine crackles are high-pitched, short, popping sounds heard during inspiration, often due to fluid in the small airways or alveoli.
Coarse crackles are loud, low-pitched, bubbling sounds heard during inspiration, typically due to the presence of secretions in the larger airways.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
C. This entry is factual and avoids assumptions about how the client ended up on the floor, focusing instead on the sequence of events as discovered by the recorder. It is important to avoid speculation and to document only what is directly observed or verifiable.
A. This option provides a clear description of the situation: the client was found on the floor, and it attributes the fall to getting tangled in bed linens. However, it includes an assumption of how the client fell.
B. This option indicates that the client fell out of bed and did push the call button for assistance. While it acknowledges the fall and the use of the call button, it doesn't specify who found the client on the floor or the circumstances surrounding the discovery.
D. This option suggests that the client called for assistance after falling out of bed due to being tangled in bed linens. It mentions the sequence of events (tangled in bed linens first, then called for assistance), but it doesn't specify who found the client on the floor or the action taken thereafter.
Correct Answer is D
Explanation
D. Before administering a cleansing enema, the client is typically instructed to assume a left-side lying position with the right knee bent. This position helps to facilitate the flow of the enema solution into the colon and allows for better retention of the solution. It also helps to prevent leakage and discomfort during the procedure.

A. Drinking water before administering an enema can help hydrate the client and promote normal bowel function. However, it is not typically a specific instruction related to the administration of the enema itself. Hydration is generally beneficial for bowel health but is not directly related to the enema procedure.
B. After administering the enema solution, the client should be instructed to hold the solution in the bowel for a sufficient amount of time to allow it to soften and loosen stool. The exact duration can vary based on the type and purpose of the enema, but typically, the client is encouraged to retain the solution for a specified period (as instructed by the healthcare provider) before evacuating.
C. This instruction is unrelated to the administration of a cleansing enema. Breathing techniques may be taught for relaxation or to manage discomfort during procedures, but they do not specifically apply to the process of administering an enema.
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