During a respiratory assessment, the nurse observes that the patient has bilateral crackles on inspiration. What is the most likely cause of this finding?

Correct Answer: B

Rationale: The presence of bilateral crackles on inspiration suggests fluid in the lungs, which is characteristic of pulmonary edema. Pulmonary fibrosis is associated with fine, late inspiratory crackles. Pneumonia typically presents with focal crackles in the affected area. Asthma is characterized by wheezing rather than crackles. Therefore, the correct answer is B as it aligns with the clinical presentation of bilateral crackles on inspiration in pulmonary edema.

Correct Answer: A

Rationale: Step 1: A weak and thready pulse indicates poor perfusion due to decreased blood volume. Step 2: Hypovolemia refers to low blood volume, leading to a weak pulse. Step 3: Hypervolemia is an excess of blood volume, which would not cause a weak pulse. Step 4: Aortic stenosis affects the heart valves, not directly causing a weak pulse. Step 5: Peripheral artery disease results in decreased blood flow to extremities, not affecting the pulse in general. Conclusion: The correct answer is A (Hypovolemia) because it directly correlates with the presentation of a weak and thready pulse, while the other choices are not the primary cause of this finding.

Correct Answer: B

Rationale: The correct answer is B: Pleuritis. A pleural friction rub is caused by inflammation of the pleura, the lining of the lungs and chest cavity. This rubbing together of inflamed surfaces creates a characteristic grating sound. Pleuritis is the most likely cause of this finding because it directly involves the pleura. Pneumonia (A) typically presents with crackles or decreased breath sounds. Pulmonary embolism (C) usually manifests with sudden onset chest pain and shortness of breath. Chronic obstructive pulmonary disease (D) may present with wheezing or prolonged expiration but not a pleural friction rub.

Correct Answer: D

Rationale: It does not do anything to defend the body, is not true and thus the correct answer. Fever, an elevated body temperature (also called pyrexia), is a defense mechanism against infection, enhancing immune responses like white blood cell activity and inhibiting pathogen growth. Fever is a sign of illness, is true, as it often signals infection or inflammation. It is the same as pyrexia or hyperthermia, is partially true; fever and pyrexia are synonymous, but hyperthermia (uncontrolled heat rise) differs. It is reflected through an increase of body temperature, is true by definition. Choice D is false because fever actively aids immunity, raising temperature to fight microbes, making it the statement that does not hold, per the questions intent.

Correct Answer: A

Rationale: Convection involves heat loss through air movement, such as a fan blowing cool air over the body. Turning off the fan directly addresses this by reducing airflow, minimizing heat dissipation. Removing an ice pack relates to conduction, not convection, as it involves direct contact rather than air movement. Reducing the room temperature might affect evaporation or overall comfort but doesnt target convection specifically. Increasing the room temperature could influence evaporation or radiation but doesnt stop the convective process caused by moving air. Choice A is the best response because it aligns with the mechanism of convection, where warm air around the body is replaced by cooler moving air. This intervention is practical and effective in a clinical setting, reflecting the nurses understanding of heat loss principles and patient thermoregulation.