Which of the following would be considered an abnormal finding and require prompt follow up when auscultating breath sounds?
Vesicular sounds at the apex of the lungs.
Wheezes on inspiration.
Vesicular sounds at the base of the lungs on the posterior chest
Rhonchi that disappear with coughing.
The Correct Answer is B
Auscultating breath sounds is an essential component of a respiratory assessment. The following breath sounds can be heard during auscultation: Vesicular, Bronchial, Bronchovesicular, Crackles, Wheezes, and Rhonchi.
Vesicular sounds at the apex of the lungs (a) and vesicular sounds at the base of the lungs on the posterior chest (c) are normal findings. Vesicular sounds are soft and low-pitched, heard during inspiration, and are indicative of air moving through small airways and alveoli. The vesicular sounds are louder at the base of the lungs, where there is more alveolar tissue.
Rhonchi that disappear with coughing (d) can be normal or abnormal findings. Rhonchi are low-pitched, continuous sounds that are heard during inspiration and expiration. They are produced by the movement of air through narrowed or obstructed airways. If the rhonchi disappear with coughing, it may indicate that the airway has cleared.
Wheezes on inspiration (b) are abnormal findings and require prompt follow-up. Wheezes are high-pitched, whistling sounds heard during inspiration and expiration. They are indicative of air moving through narrowed airways and can be a sign of an underlying respiratory condition such as asthma, chronic obstructive pulmonary disease (COPD), or bronchitis. Prompt follow-up is necessary to diagnose and manage the underlying condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Nurses are mandated reporters, meaning they are legally required to report any suspected or confirmed cases of child, elder, or vulnerable adult abuse or neglect to the appropriate authorities, such as child protective services or adult protective services. This duty applies regardless of whether the abuse or neglect was disclosed by the victim or observed by the nurse.
While nurses may choose to involve family members or refer the individual to social services, these actions do not replace the legal obligation to report abuse or neglect. Failure to report can result in legal and professional consequences for the nurse.
Correct Answer is D
Explanation
This response demonstrates respect for the client's religious beliefs and a willingness to work with the client to meet their needs. It also opens up a dialogue between the nurse and the client to develop a plan of care that is consistent with the client's beliefs and values.
Option a, "Fasting is harmful to your body," is not an appropriate response as it does not respect the client's religious beliefs and may be perceived as insensitive or disrespectful.
Option b, "You must have food during times of illness," may be accurate in some situations, but it is not relevant to the client's request to fast during Ramadan.
Option c, "I will let your healthcare provider know that you need to be discharged," is not an appropriate response as it does not address the client's request to fast during Ramadan and may be perceived as dismissive or unhelpful.
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