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 B
Explanation
B. Before, during, and after providing hygiene care, the nurse should continually assess the client's response to activity. Signs such as increased heart rate, shortness of breath, fatigue, or discomfort should be monitored closely. Assessing the client's response allows the nurse to adjust care activities as needed to prevent exacerbation of symptoms or complications.
A. Administering oxygen may be necessary if the client has respiratory compromise or if oxygen saturation levels are low during activities. However, this intervention should be based on the client's specific needs as assessed by the nurse and should not necessarily be a routine intervention
C Providing regular rest periods is an important intervention for clients with activity intolerance. However, the assessment will guide how and when these interventions should be implemented.
D. Fowler's position are also important, but the assessment will guide how and when these interventions should be implemented.
Correct Answer is A
Explanation
A. The psychomotor domain involves the development of physical skills and the ability to manipulate objects. When the client performs a return demonstration of using the incentive spirometer, they are demonstrating their ability to coordinate their muscles and movements to correctly operate the device. This includes actions such as inhaling deeply, maintaining proper technique, and achieving the desired lung volume.
B The cognitive domain pertains to the acquisition and application of knowledge and intellectual skills. Understanding how the incentive spirometer works, its purpose in improving lung function post-surgery, and the correct technique for using it all fall under cognitive learning. The client must grasp the
Rationale behind using the spirometer to promote effective breathing and prevent complications like atelectasis.
C. Imitation involves observing and copying someone else's actions. In the context of using an incentive spirometer, the initial demonstration by the nurse serves as a model for the client to imitate. After receiving instructions and observing the nurse's demonstration, the client imitates the correct technique during the return demonstration. However, imitation alone does not fully capture the learning domain demonstrated by the client.
D. The affective domain focuses on attitudes, values, beliefs, and emotions. While using the incentive spirometer involves physical and cognitive skills, it also involves motivation and willingness to engage in the activity as prescribed by the healthcare provider. This domain encompasses the client's commitment to following through with spirometer use as part of their recovery and adherence to the healthcare plan.
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