Nokea
A patient's chest x-ray examination indicates fluid in both lung bases. Which of the ff. signs or symptoms present during the nurse's assessment most reflects these x-ray examination findings?
Correct Answer: C
Rationale: The presence of fluid in both lung bases, as indicated by the chest x-ray examination, suggests the possibility of pulmonary congestion or fluid accumulation in the lungs. Bilateral crackles, also known as rales, are a common clinical finding associated with pulmonary edema. Crackles are discontinuous, brief, popping sounds heard on auscultation of the lungs. These adventitious breath sounds occur when air passes through fluid in the small airways or alveoli. Therefore, the presence of bilateral crackles during the nurse's assessment would most reflect the x-ray examination findings of fluid in both lung bases. Fatigue, peripheral edema, and jugular vein distention may also be present in conditions involving fluid overload, such as heart failure, but bilateral crackles specifically point to the presence of fluid in the lungs.