What is the term used for a high-pitched musical sound in clients during a respiratory assessment?

Correct Answer: B

Rationale: A high-pitched musical sound during breathing is wheezing, caused by air passing through narrowed airways, often due to asthma, allergies, or obstruction. Stridor is a harsh, high-pitched sound from upper airway obstruction, distinct from wheezing's expiratory nature. Crowing resembles a rooster's call, linked to laryngospasm, not a musical tone. A sigh is a deep breath, not pathological. Wheezing's recognition guides interventions like bronchodilators, addressing underlying inflammation or constriction, crucial for restoring normal respiration and preventing hypoxia.

Correct Answer: C

Rationale: Extracellular fluid loss (e.g., dehydration) reduces blood volume, causing a rapid, thready pulse as the heart compensates for hypovolemia. Distended jugular veins suggest fluid overload, not loss. Elevated hematocrit reflects hemoconcentration, but pulse is a more immediate sign. Increased sodium occurs with water loss, not always fluid volume. Nurses monitor pulse to detect early shock, guiding fluid replacement to restore circulation and prevent organ damage.

Correct Answer: D

Rationale: End-stage renal disease impairs potassium excretion, causing hyperkalemia as kidneys fail to filter excess. Crohn's affects absorption, Cushing's alters cortisol, and heart failure impacts circulation not potassium directly. Nurses monitor levels in renal patients, adjusting diet or dialysis to prevent arrhythmias or muscle issues from high potassium, a common complication.

Correct Answer: A

Rationale: Battery is the intentional, unconsented physical contact, like striking a patient, a civil tort with legal repercussions. Negligence is unintentional harm, tort is a broader category, and crime involves criminal law. Nurses avoid battery by obtaining consent, respecting autonomy, as violations breach ethical and legal standards, risking lawsuits or discipline.

Correct Answer: D

Rationale: Aspirating urine from the tubing port with a sterile syringe is the appropriate action for obtaining a sterile urine specimen from an indwelling catheter. This maintains the closed system's integrity, minimizing infection risk by avoiding exposure to external contaminants. The port is designed for sterile sampling, ensuring the specimen reflects bladder contents accurately for testing. Using sterile gloves aids asepsis but isn't the complete action; it supports the procedure, not defines it. Opening the drainage bag introduces bacteria, risking contamination and infection. Disconnecting the catheter breaks the sterile circuit, increasing urinary tract infection likelihood contrary to best practice. Aspiration via the port, paired with aseptic technique, upholds infection control standards, ensuring patient safety and reliable diagnostic results, making it the optimal nursing action.