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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Circumduction is a movement that involves the circular rotation of a limb, such as an arm or leg, around a fixed point. When assessing the patient's range of motion, the nurse may ask the patient to perform circumduction of their arms to evaluate their ability to move their arms in a circular motion.

A. Grade the edema on a scale of +1 to +4. B. Press the skin over the tibia. C. Have the patient plantar ﬂex their feet. D. Check one limb only.

Correct Answer is ["A","B"]

Explanation

When checking for edema in the lower extremities of a patient with Congestive heart failure, the nurse will grade the edema on a scale of +1 to +4 and press the skin over the tibia. Plantar ﬂexing the feet is not necessary for assessing edema in the lower extremities, and checking only one limb is not sufficient as edema may occur in both legs.

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Which of the following would be considered an abnormal finding and require prompt follow up when auscultating breath sounds?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing the patient's range of motion. The nurse asks the patient to circumduct his arms. When the patient asks what this means, the nurse explains:

Correct Answer is B

Explanation

The nurse is checking for edema in the lower extremities of a patient with Congestive heart failure. The nurse will do which of the following when checking for edema. (Select all that apply)

Correct Answer is ["A","B"]

Explanation

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