While auscultating a client's 1st and 2nd intercostal spaces, close to the sternal body, the nurse would document these normal breath sounds as which of the following?

Rhonchi

Crackles

Bronchovesicular

Tracheal

Answer and Explanation

The Correct Answer is C

Choice a reason:
Rhonchi are coarse, rattling respiratory sounds somewhat like snoring, usually caused by obstruction or secretion in the larger airways. They are not considered normal breath sounds and are typically heard in conditions such as chronic bronchitis.

Choice b reason:
Crackles are the sounds you will hear in a lung field that has fluid in the small airways. These sounds are commonly heard in patients with pneumonia, heart failure, and restrictive pulmonary diseases. They are not normal breath sounds.

Choice c reason:
Bronchovesicular sounds are normal breath sounds heard over the main bronchus area and over the upper right posterior lung field. They have a medium pitch and intensity and are heard on both inspiration and expiration. In a healthy individual, these sounds are expected to be heard in the 1st and 2nd intercostal spaces near the sternal body.

Choice d reason:
Tracheal breath sounds are harsh, high-pitched sounds heard when auscultating over the trachea in the neck. They are not normally heard over the intercostal spaces of the chest wall.

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Correct Answer is C

Explanation

Choice a reason:
The left temporal bone would be the expected site of lateralization for sound in a Weber test if the patient had conductive hearing loss in the left ear. However, with unilateral sensorineural hearing loss, the sound typically lateralizes to the opposite ear, which is the ear with better hearing.
Choice b reason:
Lateralization to both ears equally during the Weber test would suggest either normal hearing or symmetrical hearing loss. In the case of unilateral sensorineural hearing loss, the sound is not perceived as equal in both ears because the affected ear does not hear as well as the unaffected ear.
Choice c reason:
In a patient with unilateral sensorineural hearing loss in the left ear, the Weber test will lateralize to the right ear, which is the ear with normal hearing. This occurs because the inner ear on the affected side is not able to transmit the sound as effectively as the unaffected side, making the sound seem louder in the ear with better hearing.
Choice d reason:
Lateralization to the left ear in the Weber test would indicate conductive hearing loss in the left ear, not sensorineural hearing loss. In sensorineural hearing loss, the sound vibrates to the ear with better cochlear function, which would be the right ear in this case.

A. Reddened intact skin. B. Skin loss involving up to the subcutaneous tissue (fat). C. Skin loss involving up to the dermis layer. D. Exposed bone.

Correct Answer is B

Explanation

Choice A reason:

Reddened intact skin is typically associated with a stage 1 pressure ulcer, where the skin is not yet broken but shows signs of redness. This stage indicates that the skin is under pressure and may be at risk for further breakdown if the pressure is not relieved.

Choice B reason:

A stage 3 pressure ulcer involves full-thickness skin loss that extends into the subcutaneous tissue layer but does not involve underlying muscle or bone. The ulcer presents as a deep crater, and there may be slough or eschar present. It is important to manage these ulcers carefully to prevent further deterioration and complications such as infection.

Choice C reason:

Skin loss involving up to the dermis layer is characteristic of a stage 2 pressure ulcer. In this stage, the epidermis and part of the dermis are lost, creating a shallow open wound or blister. This stage is less severe than stage 3 and requires different management strategies to promote healing and prevent progression.

Choice D reason:

Exposed bone is indicative of a stage 4 pressure ulcer, which is the most severe stage. It involves full-thickness skin loss with extensive destruction, possibly including muscle, tendon, or bone exposure. These ulcers are at high risk for serious infections, including osteomyelitis, and require aggressive medical and surgical intervention to heal.

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While auscultating a client's 1st and 2nd intercostal spaces, close to the sternal body, the nurse would document these normal breath sounds as which of the following?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient is diagnosed with left ear unilateral sensorineural hearing loss. During the performance of the Weber test, the nurse expects lateralization of the sound/vibration to the:

Correct Answer is C

Explanation

A nurse is assessing a client who has a pressure ulcer. The nurse should recognize which of the following findings is a manifestation of a stage 3 pressure ulcer?

Correct Answer is B

Explanation

The nurse is preparing to percuss a client's anterior chest area. Which approach will the nurse use for this assessment?

A nurse educator is presenting at a continuing education seminar for nurses. As part of his presentation, he is emphasizing the prevention of skin breakdown in immobile patients who have suffered from a stroke. The level of prevention being discussed by the nurse educator is:

During an assessment of the ear structures, the nurse would expect to identify which structure as part of the middle ear?

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