The nurse is assessing a patient's lungs and hears wheezing during exhalation. What is the most likely cause of this finding?

Correct Answer: A

Rationale: The correct answer is A: Asthma. Wheezing during exhalation is a common characteristic of asthma due to airway constriction. In asthma, the airways become inflamed and narrowed, leading to difficulty in breathing and wheezing sounds during exhalation. Asthma is a chronic condition that can be triggered by various factors such as allergens or exercise. Summary of Incorrect Choices: B: Pulmonary fibrosis - Pulmonary fibrosis is characterized by scarring of lung tissue, leading to stiff and less flexible lungs. It typically presents with crackles on auscultation, not wheezing. C: Pneumonia - Pneumonia is an infection of the lung tissue, usually presenting with crackles or decreased breath sounds, not typically wheezing. D: Pulmonary embolism - Pulmonary embolism is a blockage in the pulmonary artery, often causing sudden shortness of breath and chest pain, but not typically associated with whe

Correct Answer: A

Rationale: The correct answer is A: Aortic stenosis. This is indicated by a high-pitched, blowing sound during systole known as an ejection murmur. Aortic stenosis involves narrowing of the aortic valve, causing turbulent blood flow during systole. Mitral valve prolapse (B) presents with a mid-systolic click and late systolic murmur. Tricuspid regurgitation (C) results in a holosystolic murmur. Pulmonary regurgitation (D) typically presents with a diastolic murmur.

Correct Answer: C

Rationale: 37.7 degrees Celsius (rectal), is correct because newborns normal rectal temperature ranges from 36.6°C-38°C (97.9°F-100.4°F), with 37.7°C being typical. Oral (Choice A) isnt used in newborns due to safety and inaccuracy. 37°C axillary, is too low; axillary readings are 0.5°C-1°C below rectal (e.g., 36.5°C-37.2°C). 36.8°C axillary, fits axillary norms but isnt the questions focus. Rectal is the gold standard for neonates, reflecting core temperature despite their immature thermoregulation. Pediatric guidelines support 37.7°C as a common rectal value, making C the precise answer based on clinical practice.

Correct Answer: C

Rationale: Postoperative patients require careful assessment before rectal temperature measurement due to potential risks. Platelet count is critical because low platelets (thrombocytopenia) increase bleeding risk from rectal trauma, a concern after any surgery, even oral. Pain assessment is important but not specific to rectal contraindications unless related to rectal discomfort, which isn't indicated here. Pulse rate monitoring doesn't directly impact rectal temperature safety unless cardiac issues (e.g., post-MI) are present, which isn't the case. A fecal occult blood test detects bleeding but isn't a pre-measurement necessity. Choice C is correct as it addresses a key contraindication—bleeding risk—ensuring patient safety. This reflects nursing judgment in evaluating hematologic status before invasive temperature methods, especially post-surgery.

Correct Answer: D

Rationale: A temperature of 96.8°F (36°C) is slightly low but within normal diurnal variation (lowest at night). Waiting 30 minutes to recheck confirms if it's a trend or artifact, avoiding overreaction. Calling the provider is premature for a non-critical value without symptoms. Lowering it further is illogical for hypothermia. Adding a blanket assumes hypothermia without confirmation. Choice D is correct, reflecting nursing judgment to monitor trends, aligning with circadian temperature dips and post-surgical assessment protocols.