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A nurse is auscultating the lungs of a client who has pleurisy. Which of the following adventitious breath sounds should the nurse expect to hear?

A.

Popping sounds

B.

Loud, gating sounds

C.

Snoring sounds

D.

Squeaky, musical sounds

Answer and Explanation

The Correct Answer is B

Rationale:

 

A. Popping sounds, also known as crackles, are typically associated with fluid in the alveoli, often seen in conditions like pneumonia or heart failure, not pleurisy.

 

B. Loud, grating sounds, known as pleural friction rub, are characteristic of pleurisy. This sound is produced by the inflamed pleural surfaces rubbing together during respiration.

 

C. Snoring sounds, or rhonchi, are usually heard in conditions involving airway obstruction by mucus, such as bronchitis, rather than pleurisy.

 

D. Squeaky, musical sounds, or wheezing, are associated with airway narrowing, such as in asthma or chronic obstructive pulmonary disease (COPD), and are not typically heard in pleurisy.


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View Related questions

Correct Answer is C

Explanation

Rationale:

A. Hemoglobin A1C reflects average blood glucose levels over the past 2 to 3 months, not just after meals, so this statement is not fully accurate.

B. A high A1C indicates chronically high blood glucose levels, not low blood sugar levels, so this statement would be misleading.

C. An A1C of 9% indicates that the client's average blood sugar has been high over the past few months, which increases the risk of diabetes-related complications.

D. While a high A1C may suggest variability in blood glucose levels, the more accurate statement is that the average blood glucose is high, which is what the A1C primarily reflects

Correct Answer is A

Explanation

Rationale:

A. A rapid weight gain, such as a 5 lb increase in one day, is a strong indicator of fluid overload, particularly in clients with end-stage kidney disease. This excess fluid retention can lead to complications like pulmonary edema and congestive heart failure.

B. An oxygen saturation of 93% is slightly low but not a direct indicator of fluid overload; it may be related to other factors like anemia or underlying lung disease.

C. Normal skin turgor, where the skin returns to its previous position after being pinched, does not indicate fluid overload. In fluid overload, you might see pitting edema, where the skin does not return immediately.

D. Flattened neck veins would suggest a lack of fluid, not an overload. In fluid overload, you would expect to see distended neck veins (jugular venous distension).

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