6. The nurse is evaluating a 63-year-old female patient who has been admitted with worsening heart failure. During the physical examination, the nurse uses a stethoscope to listen to the patient’s lung fields. The patient presents with shortness of breath, a cough that worsens when lying down, and fatigue. Which type of breath sounds is the nurse most likely to auscultate that are typically associated with heart failure?

 A. Tracheal

B. Fine crackles

C. Coarse crackles

D. Friction rubs

E. Wheezes

F. Stridor

G. Pleural knock

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7. A nurse is attending to a 35-year-old patient with a history of asthma who presents to the emergency department in the midst of an acute asthma exacerbation. The patient, who was initially wheezing loudly, suddenly has no audible wheezing and the nurse cannot auscultate breath sounds. The patient appears anxious and is using accessory muscles to breathe. Considering the change in respiratory status, what is the most likely explanation for the absence of wheezing?

A. The asthma attack has resolved.

B. The airways are so constricted that air cannot pass through.

C. The inflammation within the airways has subsided.

D. Fine crackles have replaced the wheezes due to fluid in the airways.

E. The patient is holding their breath subconsciously due to anxiety.

F. A foreign body has obstructed the airway passage.

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8. A nurse is caring for a 22-year-old individual with a known diagnosis of epilepsy. During the nurse’s shift, the patient begins to have a tonic-clonic seizure. During the active phase of the seizure, which of the following actions should the nurse take? Select all that apply. 

A. Place the patient on their back, remove dangerous objects from the immediate vicinity, and insert a padded tongue depressor.

B. Place the patient in a lateral position (on their side), remove any hazardous objects nearby, and prepare to use a bite block if needed.

C. Position the patient supine (on their back), clear the area of any items that might cause injury, and restrain their limbs gently.

D. Turn the patient to a side-lying position, ensure the environment is safe from potential hazards, and use a pillow or a hand to protect the head.

E. Keep the patient in a prone position, secure the perimeter for safety, and monitor their respiratory status closely.

F. Roll the patient onto their side to prevent aspiration, remove objects that could cause harm, and observe for cessation of seizure activity.

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9. After insertion of a chest tube for a pneumothorax, a client becomes hypotensive with neck vein distention, tracheal shift, absent breath sounds, and diaphoresis. Nurse Amanda suspects a tension pneumothorax has occurred. What cause of tension pneumothorax should the nurse check for?

 A. Infection of the lung

B. Kinked or obstructed chest tube

C. Excessive water in the water-seal chamber

D. Excessive chest tube drainage

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10. The nurse is providing lunch to a 68-year-old male patient with a history of stroke which has affected his swallowing reflex. As the patient begins to eat, he suddenly starts choking on a piece of food but is coughing loudly and forcefully. Observing this, what should the nurse do?

A. Assist the patient to stand up and perform the abdominal thrust maneuver immediately.

B. Lay the patient down and prepare to perform back blows and chest thrusts.

C. Exit the room quickly to summon for additional help from the healthcare team.

D. Stay with the patient, encourage him to keep coughing, and monitor him closely.

E. Provide a drink of water to help the patient swallow the obstructing food.

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