Nokea
Which of the following are normal breath sounds?
- A. Sounds heard over the trachea - medium pitch
- B. Sounds heard between the trachea and upper lungs - loud
- C. Sounds heard over the lung fields - quiet and low-pitched
- D. Sounds that are discrete - continuous and musical
Correct Answer: C
Rationale: The correct answer is C. Normal breath sounds over the lung fields are vesicular, characterized as quiet and low-pitched. A is incorrect because bronchial breath sounds over the trachea are high-pitched and loud. B is incorrect as these intermediate sounds occur near large airways, not throughout the lung fields. D describes adventitious sounds like wheezing or crackles, which are abnormal.
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The lungs move easily within their protective sacs due to
- A. intrapleural fluid.
- B. leaking plasma.
- C. blood.
- D. mucus.
Correct Answer: A
Rationale: The correct answer is A: intrapleural fluid. Intrapleural fluid reduces friction between the lungs and the chest wall, allowing them to move easily during breathing. This fluid creates a lubricated surface that facilitates smooth movement. Leaking plasma (B) and mucus (D) do not provide the necessary lubrication for lung movement. Blood (C) plays a role in oxygen exchange but does not directly contribute to the ease of lung movement within the pleural sacs.
Your client with pneumonia is being discharged today. Which of the following physical findings would lead the nurse to believe the client is appropriate for discharge. Select all that apply.
- A. Decreased tactile fremitus in left base
- B. Increased fatigue when walking
- C. SpO2 98% at rest
- D. Respiratory rate 30 breaths/minute
Correct Answer: C
Rationale: The correct answer is C: SpO2 98% at rest. This indicates adequate oxygenation, a crucial aspect of recovery from pneumonia. A: Decreased tactile fremitus suggests consolidation, indicating ongoing infection. B: Increased fatigue suggests continued weakness. D: A respiratory rate of 30 breaths/minute is elevated and indicates respiratory distress, not readiness for discharge.
The volume of air that can be exhaled after normal exhalation is the
- A. tidal volume
- B. residual volume
- C. inspiratory reserve volume
- D. expiratory reserve volume
Correct Answer: D
Rationale: The correct answer is D: expiratory reserve volume. After normal exhalation (tidal volume), the expiratory reserve volume represents the additional volume of air that can be forcefully exhaled. This volume is used during activities requiring increased breathing effort. Choices A and C are incorrect because tidal volume is the volume of air inhaled or exhaled during normal breathing, and inspiratory reserve volume is the extra volume of air that can be inhaled after a normal inhalation. Choice B, residual volume, is the volume of air remaining in the lungs after maximal exhalation and cannot be exhaled voluntarily.
A nurse is providing care after auscultating a client's breath sounds. Which assessment finding is correctly matched to the nurse's primary intervention?
- A. Hollow sounds are heard over the trachea. The nurse increases the oxygen flow rate.
- B. Crackles are heard in bases. The nurse encourages the client to cough forcefully.
- C. Wheezes are heard in central areas. The nurse administers an inhaled bronchodilator.
- D. Vesicular sounds are heard over the periphery. The nurse has the client breathe deeply.
Correct Answer: C
Rationale: The correct answer is C because wheezes indicate narrowing of airways, requiring bronchodilation. Step 1: Identify the assessment finding (wheezes). Step 2: Understand that wheezes indicate airway constriction. Step 3: Appropriately intervene by administering a bronchodilator to dilate the airways and improve breathing. Other choices are incorrect because: A: Increasing oxygen flow rate does not address airway constriction. B: Encouraging coughing for crackles does not address airway narrowing. D: Deep breathing for vesicular sounds does not target airway constriction.
A male client with chronic obstructive pulmonary disease (COPD) is recovering from a myocardial infarction. Because the client is extremely weak and can't produce an effective cough, the nurse should monitor closely for:
- A. Pleural effusion
- B. Pulmonary edema
- C. Atelectasis
- D. Oxygen toxicity
Correct Answer: C
Rationale: The correct answer is C: Atelectasis. In a client with COPD recovering from a myocardial infarction, the weakened state and ineffective cough can lead to the collapse of alveoli, causing atelectasis. This condition can further impair gas exchange and oxygenation, leading to respiratory distress. Monitoring for atelectasis is crucial to prevent complications. Pleural effusion (A) and pulmonary edema (B) are not directly related to the client's condition and symptoms. Oxygen toxicity (D) is a potential concern with high oxygen therapy but is not the most immediate risk for this client scenario.