A Nurse Assessing a Client's Lung Sounds Hears Continuous Low-Pitched Harsh Rattling Sounds Over the Client's Trachea That Are Most Evident on Expiration and Ar

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Sample questions from A Nurse Assessing a Client's Lung Sounds Hears Continuous Low-Pitched Harsh Rattling Sounds Over the Client's Trachea That Are Most Evident on Expiration and Ar

This material has 90 questions with answers and rationales. Here are the first 5.

1. 1.In a medical-surgical unit, a 67-year-old client with bronchitis has a frequent productive cough, RR 20/min, and SpO2 95% on room air. The nurse hears continuous low-pitched, coarse rattling sounds over the trachea that are louder during expiration. Which sound should the nurse document?

   • A.Pleural friction rub
   • B.Rhonchi
   • C.Inspiratory stridor
   • D.Fine crackles

   Rationale: Rhonchi are continuous, low-pitched, coarse sounds associated with secretions in larger airways and may be heard over the trachea. Fine crackles are brief, discontinuous sounds, often heard at the lung bases. A friction rub is grating, while stridor is a high-pitched sound that can signal upper-airway obstruction.

2. 2.During a home visit, a 74-year-old client with chronic bronchitis has coarse rattling sounds over the upper chest, RR 22/min, and SpO2 93% on the client's usual oxygen. Which action should the nurse take first to evaluate whether the sounds are caused by secretions?

   • A.Place the client supine and auscultate again
   • B.Request an immediate chest radiograph
   • C.Increase the oxygen flow rate by 2 L/min
   • D.Ask the client to cough, then auscultate again

   Rationale: Rhonchi can change or clear after coughing, so reassessment after a cough helps determine whether airway secretions are contributing. Increasing oxygen without evidence of worsening hypoxemia is not the first step. Supine positioning may impair ventilation, and imaging is not needed before completing this bedside assessment.

3. 3.Refer to the client's chart. Which actions should the nurse take in response to the change in respiratory findings? Select all that apply.

   • A.Withhold all fluids regardless of the prescription
   • B.Place the client flat to promote drainage
   • C.Position the client upright
   • D.Document the change and report persistent deterioration
   • E.Encourage an effective cough if the client can tolerate it
   • F.Reassess breath sounds and oxygenation after coughing

   Rationale: Upright positioning can improve ventilation, and coughing may mobilize secretions associated with rhonchi. Reassessment after coughing helps determine whether the sound and oxygenation improve; persistent deterioration should be documented and reported. Lying flat can impair breathing, and fluids should not be restricted without a clinical indication or prescription.

4. 4.At change of shift on a respiratory unit, a 59-year-old client with pneumonia has rhonchi that persist after coughing, RR 24/min, and SpO2 91% on room air. Which information is most important to communicate to the oncoming nurse?

   • A.The sounds persist after coughing and oxygen saturation is 91%
   • B.The client prefers water at room temperature
   • C.The client slept for 5 hours overnight
   • D.The client has a family visit scheduled at noon

   Answer and rationale are in the full material.

5. 5.In an outpatient clinic, a 46-year-old client with asthma has low-pitched rattling sounds over the central chest, RR 18/min, and SpO2 97% on room air. The sounds lessen after coughing. Which interpretation is most appropriate?

   • A.The sounds confirm pulmonary edema
   • B.The client has a fixed upper-airway obstruction
   • C.The sounds are consistent with airway secretions that moved with coughing
   • D.The sounds are diagnostic of a pneumothorax

   Answer and rationale are in the full material.