The nurse completes a shift assessment on a patient admitted in ...

[NguyenJ]

The nurse completes a shift assessment on a patient admitted in the early phase of heart failure. When auscultating the patient's lungs, which finding would the nurse most likely hear?
 
  a. Continuous rumbling, snoring, or rattling sounds mainly on expiration
  b. Continuous high-pitched musical sounds on inspiration and expiration
  c. Discontinuous, high-pitched sounds of short duration heard on inspiration
  d. A series of long-duration, discontinuous, low-pitched sounds during inspiration

Question 2

A diabetic patient's arterial blood gas (ABG) results are pH 7.28; PaCO2 34 mm Hg; PaO2 85 mm Hg; HCO3 18 mEq/L. The nurse would expect which finding?
 
  a. Intercostal retractions
  b. Kussmaul respirations
  c. Low oxygen saturation (SpO2)
  d. Decreased venous O2 pressure

[macybarnes]

Answer to Question 1

ANS: C
Fine crackles are likely to be heard in the early phase of heart failure. Fine crackles are discontinuous, high-pitched sounds of short duration heard on inspiration. Rhonchi are continuous rumbling, snoring, or rattling sounds mainly on expiration. Course crackles are a series of long-duration, discontinuous, low-pitched sounds during inspiration. Wheezes are continuous high-pitched musical sounds on inspiration and expiration.

Answer to Question 2

ANS: B
Kussmaul (deep and rapid) respirations are a compensatory mechanism for metabolic acidosis. The low pH and low bicarbonate result indicate metabolic acidosis. Intercostal retractions, a low oxygen saturation rate, and a decrease in venous O2 pressure would not be caused by acidosis.