Answer to Question 1
A
A. RhonchiLoud, low-pitched, rumbling coarse sounds heard most often during inspiration or expiration; may be cleared by coughing.
B. WheezesHigh-pitched, continuous musical sounds like a squeak heard continuously during inspiration or expiration; usually louder on expiration; do not clear with coughing.
C. Pleural friction rubDry, grating quality heard best during inspiration; does not clear with coughing; heard loudest over lower lateral anterior surface.
D. CracklesFine crackles are high-pitched, fine, short, interrupted crackling sounds heard during end of inspiration, usually not cleared with coughing.
Answer to Question 2
D
The primary purpose of wet-to-dry dressings is to mechanically debride a wound. The moistened contact layer of the dressing (primary dressing) increases the absorptive ability of the dressing to collect exudate and wound debris. As the dressing dries, it adheres to the wound and debrides the wound of tissue when the dressing is removed. The moistened gauze must be covered with a secondary dressing layer that is dry. It is incorrect technique and a common error by some clinicians to moisten the dried gauze before removing it. This defeats the purpose of using this type of dressing and reduces the amount of debris that the dressing will remove. Open or fluff the woven gauze that will be placed directly against the wound bed. Moisten the packing material with a noncytotoxic solution such as normal saline. Never use cytotoxic solutions.
B, The nurse teaches the postoperative client to use an incentive spirometer to expand the lungs.
The nurse uses a noninvasive bladder ultrasound to measure the client’s bladder volume.
The sounds auscultated during blood pressure measurement
Removing the sheet from underneath the client.
Testing the client’s ability to feel vibrations, the toe
Loud Music and Hearing Loss