Author Question: Upon assessment, the patient is breathing normally and has normal vesicular lung sounds. Which ... (Read 74 times)

Hungry! · **on:** Jul 22, 2018

Upon assessment, the patient is breathing normally and has normal vesicular lung sounds. Which expected inspiratory-to-expiratory breath sounds will the nurse hear?

a. The expiration phase is longer than the inspiration phase.
b. The inspiratory phase lasts exactly as long as the expiratory phase.
c. The expiration phase is 2 times longer than the inspiration phase.
d. The inspiratory phase is 3 times longer than the expiratory phase.

Question 2

On admission, a patient weighs 250 pounds. The weight is recorded as 256 pounds on the second inpatient day. Which condition will the nurse assess for in this patient?

a. Anorexia
b. Weight loss
c. Fluid retention
d. Increased nutritional intake

hanadaa · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

ANS: D
Vesicular breath sounds are normal breath sounds; the inspiratory phase is 3 times longer than the expiratory phase. Bronchovesicular breath sounds have an inspiratory phase equal to the expiratory phase. Bronchial breath sounds have an expiration phase longer than the inspiration phase at a 3:2 ratio.

Answer to Question 2

ANS: C
This patient has gained 6 pounds in a 24-hour period. A weight gain of 5 pounds (2.3 kg) or more in a day indicates fluid retention problems, not nutritional intake. A weight loss is considered significant if the patient has lost more than 5 of body weight in a month or 10 in 6 months. A downward trend may indicate a reduction in nutritional reserves that may be caused by decreased intake such as anorexia.