When auscultating the lungs of an adult client, the nurse notes that low-pitched, soft breath sounds are heard over the lower lobes. How would the nurse interpret these findings?
Normal sounds auscultated up against the sternum
Bronchovesicular sounds that are normal over that location
Bronchial sounds that are normal over that location
Normal sounds auscultated over the trachea
Vesicular breath sounds that are normal in that location
The Correct Answer is E
A. Normal sounds against the sternum would not be low-pitched or soft; they would typically be more pronounced.
B. Bronchovesicular sounds are medium-pitched and are not expected in the lower lobes; they are usually heard in the central area.
C. Bronchial sounds are high-pitched and hollow, typically heard over the trachea, not in the lower lobes.
D. Normal sounds over the trachea would not be described as low-pitched or soft.
E. Vesicular breath sounds are soft, low-pitched, and normal over peripheral lung fields, including the lower lobes, making this the correct interpretation.
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Correct Answer is A
Explanation
A. Suctioning the tracheostomy is the priority action to clear secretions, which is likely the cause of the noisy, bubbly respirations. This can help the client breathe more easily.
B. Changing the tracheostomy tube is only necessary if the tube is obstructed or malfunctioning, and suctioning is generally the first step.
C. Notifying the healthcare provider may be needed if suctioning is ineffective or if complications persist, but immediate intervention is required.
D. Changing the tracheostomy dressing does not address the respiratory noise or potential secretion buildup.
E. A head-to-toe assessment may be needed, but the immediate concern is clearing the airway obstruction.
Correct Answer is ["A","D"]
Explanation
A. Demonstrating an insulin injection shows hands-on learning and mastery of the skill.
B. Attending a course does not confirm comprehension or skill.
C. Watching a nurse apply a dressing does not guarantee learning; active participation is necessary.
D. Listing healthy food choices indicates understanding of dietary education.
E. Nodding does not confirm learning; it may only indicate acknowledgment.