When auscultating the breath sounds of a client with pericarditis, the nurse would expect to find which of the following?
Friction rub
Wheezes
Rales
Rhonchi
The Correct Answer is A
A. A friction rub is the characteristic auscultatory finding in pericarditis. It is a high-pitched, scratchy sound heard best at the left lower sternal border and is caused by the inflamed pericardial layers rubbing against each other.
B. Wheezes are continuous, musical sounds usually associated with airway narrowing, such as in asthma or COPD.
C. Rales (crackles) are heard in conditions like pulmonary edema or pneumonia, not pericarditis.
D. Rhonchi are low-pitched, snoring sounds associated with mucus or obstruction in the larger airways.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Monitor blood pressure – While important, blood pressure changes are not the most sensitive or early indicator of fluid retention in heart failure.
B. Assess radial pulses – Pulse assessment can reflect cardiac output, but it does not directly indicate fluid balance.
C. Monitor bowel movements – Bowel function is not typically affected by fluid balance in heart failure and is not a relevant measure.
D. Monitor weight daily – Daily weight monitoring is the most accurate and early indicator of fluid retention in clients with heart failure. A weight gain of 2–3 pounds in a day or 5 pounds in a week may indicate fluid overload and should be reported to the healthcare provider.
Correct Answer is A
Explanation
A. Increased respiratory rate – Tachypnea (increased respiratory rate) is often the earliest compensatory sign of shock as the body attempts to correct metabolic acidosis and hypoxia by increasing oxygen intake and carbon dioxide removal.
B. Hypotension – Occurs later in the shock progression, typically when compensatory mechanisms fail.
C. Anuria – Indicates prolonged or severe shock leading to organ failure, not an early finding.
D. Decreased level of consciousness – A later sign, suggesting impaired cerebral perfusion due to worsening shock.
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