rales and rhonchi are frequently noted during an examination of lung sounds what is the difference between the two

NCLEX-RN

NCLEX RN Actual Exam Test Bank

1. Rales and rhonchi are frequently noted during an examination of lung sounds. What is the difference between the two?

A. Rales are louder.
B. Rhonchi are noted only in infants.
C. Rales occur on inspiration, rhonchi on expiration.
D. Rales are noted only in infants.

Correct answer: C

Rationale: The correct answer is that rales occur on inspiration, while rhonchi occur on expiration. Rales are typically heard during inhalation when there is fluid in the alveoli or air passages. Rhonchi, on the other hand, are caused by air passing through obstructed airways during exhalation due to secretions in the respiratory tract. Choice A is incorrect because the loudness of the sounds is not the primary distinguishing factor between rales and rhonchi. Choice B is incorrect as rhonchi can be heard in individuals beyond infancy. Choice D is incorrect as rales can be present in patients of various age groups, not just infants.

2. Which is the most effective action for controlling the spread of infection?

A. Thorough hand hygiene
B. Wearing gloves and masks when providing direct client care
C. Implementing appropriate isolation precautions
D. Administering broad-spectrum prophylactic antibiotics

Correct answer: A

Rationale: Thorough hand hygiene is the most effective action for controlling the spread of infection as hands are a common source of transmission. Regular and routine hand hygiene helps prevent the movement of potentially infective materials. Wearing gloves and masks is important when providing direct client care to protect both the caregiver and the patient, but it is not as effective as thorough hand hygiene in preventing overall infection spread. Implementing appropriate isolation precautions is necessary for clients with known communicable diseases, but it is not as universally effective in preventing the spread of various infections. Administering broad-spectrum prophylactic antibiotics is not an appropriate measure for controlling the spread of infection as routine use can lead to superinfection and the development of resistant organisms.

3. The NFPA diamond has four colors. The blue diamond:

A. indicates hazards to health.
B. designates that it is safe to use water to put out this type of fire.
C. indicates that ice is necessary to treat an injury with this type of chemical.
D. indicates that the chemical may be incinerated upon disposal.

Correct answer: A

Rationale: The National Fire Protection Agency (NFPA) uses a safety diamond to communicate the level of threat posed by a specific chemical. The blue diamond in the NFPA diamond system signifies potential health hazards associated with the use of that chemical. Choice B is incorrect because the blue diamond does not indicate anything about using water to extinguish fires. Choice C is incorrect as the NFPA diamond does not provide information on treating injuries. Choice D is also incorrect as the blue diamond does not suggest incineration upon disposal; it pertains to health hazards.

4. A client is being seen for disrupted sleep patterns. The nurse encourages the client to verbalize feelings about sleep and inability to maintain adequate sleep habits. What is the rationale for this action?

A. The client most likely has a mental illness that should be treated before addressing sleep issues
B. The client may have unrecognized anxiety or fear that could be contributing to poor sleep habits
C. The client may become tired once they start talking
D. None of the above

Correct answer: B

Rationale: Clients experiencing disrupted sleep patterns may have underlying anxiety or fear contributing to their poor sleep habits. Encouraging clients to verbalize their feelings about sleep allows them to address any negative emotions that may be impacting their ability to sleep well. By working through these issues, clients may experience increased peace and relaxation, which can help promote better sleep. Option A is incorrect because assuming a mental illness without evidence can lead to mismanagement of the client's care. Option C is incorrect as it does not address the underlying emotional factors affecting the client's sleep patterns. Option D is incorrect as there is a specific rationale for encouraging the client to verbalize their feelings about sleep.

5. When considering the concepts related to blood pressure, which statement best describes the concept of mean arterial pressure (MAP)?

A. MAP is the pressure of the arterial pulse.
B. MAP reflects the stroke volume of the heart.
C. MAP is the pressure forcing blood into the tissues, averaged over the cardiac cycle.
D. MAP is an average of the systolic and diastolic blood pressures and reflects tissue perfusion.

Correct answer: C

Rationale: Mean Arterial Pressure (MAP) is the pressure that forces blood into the tissues, averaged over the cardiac cycle. It is not the pressure of the arterial pulse (Choice A), nor does it directly reflect the stroke volume of the heart (Choice B). While MAP involves systolic and diastolic pressures, it is not simply an average of these two values as diastole lasts longer. Instead, MAP is closer to diastolic pressure plus one third of the pulse pressure. The best description of MAP is that it represents the pressure forcing blood into the tissues, averaged over the cardiac cycle.