While assessing breath sounds, a nurse hears crackles. What causes these lung sounds?

Moisture in air passages

Narrowed small air passages

Normal air passing through the airways

Narrowing of the upper airway

Answer and Explanation

The Correct Answer is A

The correct answer is choice A, moisture in air passages. Crackles, also known as rales, are abnormal lung sounds that can indicate a buildup of fluid in the lungs. The moisture in the air passages causes the sound of air moving through fluid or mucus, leading to a crackling sound. Crackles can be heard in conditions such as pneumonia, heart failure, and pulmonary fibrosis.

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Correct Answer is A

Explanation

The correct answer is choice A. When performing hygiene care for a client with an indwelling catheter, the nurse should plan to cleanse the catheter from the meatus outward using mild soap and warm water. This helps to prevent infection and ensure proper hygiene. Using the same cleansing cloth for cleaning the perineal area and catheter tubing (choice B) is not recommended as it can cause contamination and increase the risk of infection. The use of chlorhexidine gluconate (CHG) to cleanse the perineal area (choice C) is not necessary for routine catheter care and should only be used for specific indications such as preventing infection during surgery. Therefore, the nurse should always follow proper hygiene protocols and cleanse the catheter from the meatus outward using mild soap and warm water when caring for a client with an indwelling catheter.

A. Along either upper gum line, adjacent to an incisor. B. Deep in the posterior sublingual pocket. C. In the inferior buccal space on either side of the tongue. D. Superior to the tongue with the tip touching the hard palate.

Correct Answer is B

Explanation

A. Along either upper gum line, adjacent to an incisor:Placing the thermometer along the upper gum line near the incisors would not accurately reflect the body's core temperature. The posterior sublingual pocket provides a more reliable reading.

B. Deep in the posterior sublingual pocket:The sublingual pocket, located under the tongue toward the back, is the best place for measuring oral temperature. This area has a good blood supply from the carotid arteries, making it ideal for an accurate temperature reading.

C. In the inferior buccal space on either side of the tongue:The buccal space is not ideal for temperature measurement, as it does not have the same consistent blood supply and is more prone to error due to airflow from breathing.

D. Superior to the tongue with the tip touching the hard palate:Placing the thermometer on top of the tongue against the hard palate would result in an inaccurate reading because this location does not effectively reflect the body's core temperature.

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While assessing breath sounds, a nurse hears crackles. What causes these lung sounds?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is planning to care for a client with an indwelling catheter. Which of the following measures should the nurse implement when performing hygiene care in regards to the indwelling catheter?

Correct Answer is A

Explanation

The nurse is preparing to assess a client's oral temperature. The nurse should plan to place the thermometer probe in which area of the client's mouth?

Correct Answer is B

Explanation

Ancient has developed dysphagia secondary to a cerebrovascular accident. The doctor has ordered pureed diet with nectar thick liquids. Which of the following would be appropriate for this client?

Which of the following is the best example of a measurable client goal? The client will:

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A nurse is instructing a group of nursing students in taking vital signs and assessing a client's respiratory status. Which of the following guidelines should the nurse include? Select all that apply.

The nurse is assisting with the insertion of a nasogastric tube into a client. The nurse should place the client in which position for insertion?

While caring for a female patient with advanced multiple sclerosis, the nurse is discussing the difference between hospice and palliative care. Which statement by the patient indicates understanding of the difference between hospice care and palliative care?

A nurse is taking action and performing interventions in the nursing process to provide care for patients in a busy hospital setting. Which nursing actions best represent this step in the nursing process? Select all that apply.