Difficulty: Medium
Average Score: 67%
Simulated
Upon assessment of the lungs,the nurse hears continuous high-pitched musical sounds. This should be documented as:
Correct answer
A
Rationale
The correct answer is A: Wheezes. Wheezes are continuous high-pitched musical sounds typically heard during expiration, indicating narrowed airways. Rhonchi are low-pitched snoring or rattling sounds caused by secretions in larger airways. Fine crackles are discontinuous, high-pitched sounds heard during inspiration, caused by fluid in smaller airways. Vesicular sounds are normal breath sounds heard over most of the lung fields. In this scenario, the description matches wheezes best, indicating airway constriction.