During auscultation of the lungs, the nurse expects decreased breath sounds to be heard in which situation?
a. When the bronchial tree is obstructed
b. When adventitious sounds are present
c. In conjunction with whispered pectoriloquy
d. In conditions of consolidation, such as pneumonia
ANS: A
Decreased or absent breath sounds occur when the bronchial tree is obstructed, as in emphysema, and when sound transmission is obstructed, as in pleurisy, pneumothorax, or pleural effusion.
You might also like to view...
The postanesthesia-care unit (PACU) nurse is caring for a patient who has arrived from the operating room and is still unconscious
During the initial assessment, the nurse notices that the patient's skin is blue and dusky, so she looks, listens, and feels for breathing. She determines the patient is not breathing. The priority intervention is to: A) Check an oxygen saturation rate, continue to monitor for apnea, and perform a focused assessment. B) Treat the possible airway obstruction by tilting the head back and pushing forward on the angle of the lower jaw. C) Check the arterial pulses and place the patient in the Trendelenburg position. D) Call a code blue and then get a rapid intubation kit and prepare to reintubate.
The nurse administers intravenous magnesium sulfate to a client being treated for refractory ventricular fibrillation. The client is experiencing symptoms of deep tendon reflex impairment. The nurse interprets this as being indicative of:
a. magnesium toxicity. b. hypomagnesemia. c. expected side effect of the drug. d. anaphylactic reaction.
The Joint Commission (TJC) sets standards of care, in which an institution is required to have:
1. Limits of professional liability 2. Educational standards for nurses 3. A delineated scope of practice for health professionals 4. Written nursing policies and procedures for client care
The nurse is caring for a male client who has been diagnosed with tuberculosis. The client asks when he will be considered noninfectious. The nurse knows that a client will be considered noninfectious when the:
1. PPD is negative. 2. white blood cell count is normal. 3. sputum culture and smear are negative. 4. chest x-ray is clear.