PNLE- Fundamentals in Nursing Exam 1

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PNLE: Fundamentals in Nursing Exam 1 Text Mode – Text version of the exam 1. Jake is complaining of shortness of breath. The nurse assesses his respiratory rate to be 30 breaths per minute and do... cuments that Jake is tachypneic. The nurse understands that tachypnea means: A. Pulse rate greater than 100 beats per minute B. Blood pressure of 140/90 C. Respiratory rate greater than 20 breaths per minute D. Frequent bowel sounds Answer (C) Respiratory rate greater than 20 breaths per minute. A respiratory rate of greater than 20 breaths per minute is tachypnea. A blood pressure of 140/90 is considered hypertension. A pulse greater than 100 beats per minute is 2. The nurse listens to Mrs. Sullen’s lungs and notes a hissing sound or musical sound. The nurse documents this as: A. Wheezes B. Rhonchi C. Gurgles D. Vesicular Answer (A) Wheezes. Wheezes are indicated by continuous, lengthy, musical; heard during inspiration or expiration. Rhonchi are usually coarse breath sounds. Gurgles are loud gurgling, bubbling sounds. Vesicular breath sounds are low pitch, soft intensity on expiration. [Show More]

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