Difficulty: Medium
Average Score: 91%
Simulated
Passage / Scenario
The nurse is caring for a child diagnosed with ventricular septal defect (VSD) who is scheduled for a surgical repair tomorrow morning. When the nurse auscultates the child's lungs sounds, the nurse notes diffuse crackles and rales throughout the lung fields.The nurse interprets this assessment as which of the following?
Correct answer
D
Rationale
The correct answer is D: Pulmonary congestion. The nurse likely identified signs of fluid accumulation in the lungs, such as crackles and increased respiratory rate. This suggests pulmonary congestion, a condition where excess fluid builds up in the lungs. Foreign body aspiration (A) would present with acute respiratory distress. Systemic congestion (B) involves fluid buildup in the body, not just the lungs. Pneumonia (C) would typically show signs of infection like fever and productive cough. The correct interpretation is based on the specific signs observed, pointing towards pulmonary congestion as the most likely diagnosis.