A healthcare professional is auscultating the lungs of a client who has pleurisy. Which of the following adventitious breath sounds should the professional expect to hear?

Correct Answer: A

Rationale: The correct answer is A: Loud, scratchy sounds. Pleurisy is inflammation of the pleura, causing friction between layers of the lung lining, resulting in loud, scratchy sounds known as pleural friction rubs. Squeaky, musical sounds (B) are indicative of wheezing in conditions like asthma. Popping sounds (C) can be heard in conditions like atelectasis or pneumonia. Snoring sounds (D) are typically associated with upper airway obstruction, not pleurisy. Therefore, in the context of pleurisy, the healthcare professional should expect to hear loud, scratchy sounds during auscultation.

Correct Answer: C

Rationale: The correct answer is C: Confirming the gag reflex. Immediately following a bronchoscopy, the nurse must prioritize confirming the gag reflex to ensure the client can protect their airway. This is crucial to prevent aspiration and respiratory complications. Observing for confusion (choice A) is important but not the priority in this situation. Auscultating breath sounds (choice B) is also important but confirming the gag reflex takes precedence. Measuring blood pressure (choice D) is not directly related to the immediate post-bronchoscopy monitoring.

Correct Answer: D

Rationale: The correct answer is D: Confusion. Confusion in an older adult with community-acquired pneumonia can indicate hypoxia or sepsis affecting the brain. It is a common manifestation in elderly patients with pneumonia due to impaired gas exchange and systemic inflammatory response. Unequal pupils do not typically relate to pneumonia. Hypertension is not a common finding in pneumonia; hypotension is more likely. Tympany upon chest percussion is associated with conditions like pneumothorax, not pneumonia. Therefore, confusion is the most relevant finding in this scenario.

Correct Answer: C

Rationale: The correct answer is C: Avoid speaking for extended periods. This instruction is important to prevent strain on the vocal cords and reduce the risk of aspiration or airway irritation post-extubation. Speaking after the removal of the endotracheal tube can potentially lead to complications. Step-by-step rationale: 1. Speaking can cause strain on the vocal cords, which may lead to hoarseness or damage. 2. It is essential to allow the airway to recover and prevent irritation or inflammation. 3. Resting the voice can aid in the healing process and reduce the risk of complications. 4. Incentive spirometer use (option B) is important for lung expansion but not directly related to vocal cord rest. 5. Vital signs monitoring (option D) is crucial but does not address vocal cord care or prevention of complications. 6. Resting in a side-lying position (option A) is not directly related to vocal cord rest or post-extubation care.

Correct Answer: B

Rationale: The correct answer is B: 480 mL. For a client with an ideal weight of 60 kg, the tidal volume should be set at 6-8 mL/kg of ideal body weight. Therefore, for a 60 kg individual, the tidal volume should be between 360-480 mL. B falls within this range and is the most appropriate choice. A: 300 mL is too low and would not provide adequate ventilation for a client of this weight. C: 800 mL is too high and could lead to overventilation and potential lung injury. D: 950 mL is also too high and poses the same risks as option C. In summary, B is the correct choice as it falls within the appropriate tidal volume range based on the client's ideal weight, while the other options are either too low or too high.