NR-302 Health Assessment I - Set 5 - Part 3

Correct Answer: Consolidated lung transmitting sound to the chest wall

Air filled lung normally filters the harsh tracheal sound into a soft vesicular one. When alveoli fill with pus or fluid, that filter disappears and the raw bronchial sound reaches the chest wall undamped. Option a is incorrect because vesicular sounds are soft and low pitched, with inspiration clearly outlasting a faint expiration. The loud tubular quality described here is the opposite of what healthy peripheral lung produces. Option b is incorrect because pleural air blocks sound transmission instead of enhancing it. A pneumothorax produces diminished or absent breath sounds with hyperresonance, so nothing loud would be audible over that side of the chest. Option d is incorrect because the hairy chest artefact makes a fine crackling noise, not a tubular breath sound. It also persists regardless of respiratory phase and vanishes when the diaphragm is pressed harder.

Correct Answer: Labeling it a late entry with both times

A late entry stays honest when it announces itself and carries the hour the care actually happened alongside the hour it was written. Both times let a reader reconstruct the sequence. Option b is incorrect because a single afternoon timestamp implies the dressing was changed five hours later than it was. The chart then contradicts the wound care schedule and anyone who saw the client at midday. Option c is incorrect because squeezing text between existing lines looks like material added after the fact. Late entries go in the next open space in order, never crammed into a margin or a gap. Option d is incorrect because only the nurse who performed the care may document it. Handing the task to a colleague creates an entry about work that colleague never did, which is falsification.

Correct Answer: Inspiratory stridor in a client who just ate

Stridor is a high pitched crowing sound made by a narrowed upper airway, which makes it an airway problem. The nurse stays with the client, positions upright, and calls for help immediately. Option a is incorrect because wheezing on expiration is the expected sound of asthma and belongs to breathing rather than airway. It needs treatment once the client whose upper airway is narrowing has been secured. Option c is incorrect because basilar crackles are exactly what heart failure produces, so the finding matches the diagnosis. Expected findings of a known condition are assessed and documented, not treated as an emergency. Option d is incorrect because sputum production signals infection that will be managed with antibiotics and airway clearance. Nothing about a cough threatens the passage of air in the next few minutes, so it ranks lower.

Correct Answer: Left lower lobe collapse from atelectasis

Shallow post operative breathing closes small airways and a lobe collapses. Loss of volume pulls the trachea toward the affected side, the airless lobe percusses dull, and the plugged bronchus leaves breath sounds absent. Option a is incorrect because a large effusion adds volume and shoves the trachea away from the affected side. The direction of the shift, not the dull note, is what rules this option out here. Option b is incorrect because trapped pleural air under pressure gives hyperresonance and pushes the trachea to the opposite side, alongside hypotension and distended neck veins. This client percussed dull instead. Option d is incorrect because bronchospasm affects both lungs diffusely and produces expiratory wheeze with a resonant to hyperresonant note. A unilateral dull base with a shifted trachea points to lost volume, not to narrowed airways.

Correct Answer: "I will record the drainage volume, its color and any odor."

Volume, color and odor are properties another nurse can confirm at the next dressing change. Recording them lets the reader judge whether the drainage is changing without being handed a conclusion. Option a is incorrect because infection is a conclusion the student is not licensed to record. Warmth, redness measured in centimeters, purulent drainage and fever are the observations that should appear instead. Option b is incorrect because charting care in advance is falsification, plain and simple. Should the client refuse the bath or should the shift end before it happens, the chart already claims otherwise. Option c is incorrect because seems depressed applies a psychiatric label based on impression alone. The note should carry the flat facial expression, the tearfulness, the untouched meal tray and the client's own words.

Correct Answer: Vesicular breath sounds over normal lung

Vesicular sounds are soft, low pitched and rustling, with inspiration heard about three times longer than expiration. They are the expected finding over most peripheral lung fields, where air moves through bronchioles and alveoli. Option b is incorrect because bronchial sounds are loud, high pitched and harsh, with a distinct pause and a longer expiration. Hearing them at a peripheral base would signal consolidation rather than the healthy lung described here. Option c is incorrect because bronchovesicular sounds carry moderate pitch with inspiration and expiration equal in length. Their normal home is between the scapulae and beside the upper sternum, not down at the peripheral bases. Option d is incorrect because crackles are added, discontinuous popping noises superimposed on a breath sound. The nurse described a smooth, continuous rustling with no popping quality, so nothing adventitious was actually heard in this chest.

Correct Answer: Report the changed cough and blood streaked sputum promptly

A change in the character of a long standing smoker's cough, blood in the sputum and weight loss are red flags that call for imaging, so the provider needs this information now. Option a is incorrect because suppressing the cough treats a symptom while leaving the reason for the bleeding unexamined, and no nonprescription remedy addresses the possibility of a tumor or of tuberculosis. Option b is incorrect because normalizing the finding ignores the very detail that makes it dangerous; a cough that has altered its character in a smoker is precisely the one that must be investigated. Option c is incorrect because a delay of months allows a treatable lesion to advance, and the combination described here belongs in the category that earns imaging within days rather than routine follow-up.

Correct Answer: Lobar pneumonia with a patent bronchus

Alveoli filled with fluid, pus and cells conduct vibration far better than air filled lung, so fremitus rises over consolidation whenever the bronchus supplying that area remains open. Option b is incorrect because free air in the pleural space separates lung from chest wall and absorbs vibration, so fremitus falls or vanishes on that side instead of strengthening. Option c is incorrect because a layer of fluid between the lung and the palpating hand blocks the buzz from reaching the surface, and the expected result is decreased or absent fremitus over the collection. Option d is incorrect because hyperinflated lung holds excess air, which is a poor conductor, and the change would be bilateral rather than confined to one base beside a normal opposite side.

Correct Answer: Client pacing, wringing hands, respirations twenty four

Pacing, hand wringing and a counted respiratory rate are all things another nurse could see and verify. Anxiety is the conclusion those observations point toward, and the reader is left to draw it. Option a is incorrect because appears anxious is the nurse's inference and cannot be verified by anyone else. Two nurses watching the same client may reach different conclusions from the identical set of behaviors. Option b is incorrect because emotionally overwhelmed labels an internal state the nurse never measured, and needs reassurance states a plan. Findings and planned interventions are separate elements and do not share one line. Option d is incorrect because coping poorly is a judgment about the client rather than a record of behavior. It also carries a hint of criticism, which has no place in a clinical note.

Correct Answer: Recheck turgor over the sternum or clavicle

Loss of collagen, elastin, and subcutaneous fat makes dorsal hand skin tent in any older adult, hydrated or not. Turgor is assessed over the sternum or just below the clavicle, alongside weight, mucous membranes, and intake. Option a is incorrect because charting a deficit from an unreliable site records a conclusion the finding cannot support. The back of the hand tents from age-related tissue loss, and the entry would mislead the next clinician. Option c is incorrect because restricting fluids reverses the treatment an older adult with suspected dehydration would need. Blunted thirst and reduced concentrating ability already put this client at risk, so oral intake is encouraged rather than held. Option d is incorrect because the opposite hand shares the same thin, inelastic skin. Repeating an unreliable test on identical tissue produces the identical misleading result, so the site has to change rather than the side.