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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Notifying the health care provider immediately is not necessary, as the PR interval is at the upper limit of normal (0.20 seconds) and the client is stable.
B. Document the finding and continue to monitor the patient – A PR interval of 0.20 seconds with a normal heart rate and rhythm does not require intervention; just ongoing observation.
C. Prepare the patient for temporary pacemaker insertion – This is used for serious conduction blocks or symptomatic bradycardia, which are not present here.
D. Give atropine per agency dysrhythmia protocol – Atropine is used for symptomatic bradycardia, which this client does not exhibit.
Correct Answer is A
Explanation
A. Oliguria (low urine output) is an expected finding in hypovolemic shock due to decreased renal perfusion as blood is shunted to vital organs.
B. Hypertension is not expected; hypotension is more typical as circulating blood volume decreases.
C. Bradypnea is not common; tachypnea is expected as the body tries to compensate for decreased oxygen delivery.
D. Flushing of the skin is associated with early septic shock; in hypovolemic shock, the skin is typically cool, pale, and clammy due to peripheral vasoconstriction.
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