Special Considerations in Patient Assessment and Documentation
Special Considerations in Patient Assessment and Documentation ( 6 Questions)
A nurse is documenting the findings of a physical examination on a client who has heart failure.
Which of the following terms should the nurse use to describe crackles heard in the lungs?
Wheezes are high-pitched musical sounds heard in the lungs due to narrowed airways. They are commonly heard in clients who have asthma, chronic obstructive pulmonary disease (COPD), or bronchitis.
Rhonchi are low-pitched snoring sounds heard in the lungs due to secretions or mucus in the large airways. They are commonly heard in clients who have bronchitis, cystic fibrosis, or pneumonia.
Rales are fine, high-pitched crackling sounds heard in the lungs due to fluid accumulation or inflammation. They are commonly heard in clients who have heart failure, pneumonia, or pulmonary edema.
Stridor is a high-pitched crowing sound heard in the upper airway due to obstruction or inflammation. It is commonly heard in clients who have croup, epiglottitis, or foreign body aspiration.
Rales
Rationale: Rales are fine, high-pitched crackling sounds heard in the lungs due to fluid accumulation or inflammation. They are commonly heard in clients who have heart failure, pneumonia, or pulmonary edema.
Incorrect options:
A) Wheezes - Wheezes are high-pitched musical sounds heard in the lungs due to narrowed airways. They are commonly heard in clients who have asthma, chronic obstructive pulmonary disease (COPD), or bronchitis.
B) Rhonchi - Rhonchi are low-pitched snoring sounds heard in the lungs due to secretions or mucus in the large airways. They are commonly heard in clients who have bronchitis, cystic fibrosis, or pneumonia.
D) Stridor - Stridor is a high-pitched crowing sound heard in the upper airway due to obstruction or inflammation. It is commonly heard in clients who have croup, epiglottitis, or foreign body aspiration.