A nurse auscultates a client's lung sounds and identifies crackles in the left lower lobe. Which of the following interventions should the nurse take
Place the client on bed rest in a semi-Fowler's position.
Instruct the client to limit fluid intake to less than 2.000 mL/day.
Prepare to administer antibiotics.
Repeat auscultation after asking the client to breathe deeply and cough
The Correct Answer is A
Explanation: Crackles are abnormal lung sounds that may indicate the presence of fluid or mucus in the lungs. Placing the client on bed rest in a semi-Fowler position helps to improve lung expansion and oxygenation by reducing the pressure on the diaphragm, promoting optimal lung ventilation, and facilitating drainage of fluid from the affected area of the lung.
The other interventions are not appropriate for crackles in the left lower lobe:
B-Instructing the client to limit fluid intake to less than 2,000 mL/day is not indicated for crackles. Fluid restriction is more commonly used in conditions like congestive heart failure where there is excessive fluid retention.
C- Preparing to administer antibiotics is not the first intervention for crackles. Crackles can be caused by various conditions, and antibiotics would only be administered if there is an underlying infection requiring treatment.
D- Repeating auscultation after asking the client to breathe deeply and cough may help the nurse gather more information about the client's lung sounds, but it does not address the immediate need for improving lung expansion and oxygenation in the presence of crackles.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The client's statement, "I really want to see my first grandchild born before I die. Is that too much to ask?" indicates that the client is experiencing the stage of bargaining in the grieving process. During this stage, individuals may try to negotiate or make deals with a higher power or with fate in an attempt to postpone or change the outcome of their situation. In this case, the client is expressing a desire to live long enough to witness the birth of their first grandchild, which represents an attempt to negotiate with their illness and impending death.
It's important for the nurse to be supportive and empathetic during this stage of grieving and to provide emotional support to the client as they navigate their feelings and thoughts about their illness and impending death. Explanation: The client's statement, "I really want to see my first grandchild born before I die. Is that too much to ask?" indicates that the client is experiencing the stage of grieving known as bargaining.
In the context of the five stages of grief proposed by Elisabeth Kübler-Ross, bargaining is the third stage. During this stage, individuals may attempt to negotiate or make deals with a higher power or the universe to change the outcome of their situation. They may express thoughts like "If only I could see this happen before I die," as a way to find some sense of control or hope amidst their terminal illness.
In this scenario, the client's desire to see their first grandchild born reflects the bargaining stage, where they are trying to find meaning and hope in their terminal condition by wishing for a specific event to occur before their passing.
The other stages of grief include:
A. Anger - In this stage, individuals may feel resentful, frustrated, or outraged about their situation or the circumstances leading to their illness.
B. Acceptance - The final stage in Kübler-Ross's model, acceptance, involves coming to terms with one's imminent death and finding peace and resolution.
D. Depression - In this stage, individuals may experience profound sadness and a sense of loss related to their impending death and the life they will leave behind.
Correct Answer is B
Explanation
The nurse's feelings of sadness, poor sleep, and mild depression after the death of the terminally ill client indicate that the nurse is experiencing grief, which is a normal reaction to loss. However, if the nurse is finding it difficult to cope with the grief or if the grief is significantly impacting the nurse's daily life and well-being, seeking therapy is the best action.
Option B suggests seeking therapy for dysfunctional grief, which can provide the nurse with professional support and coping strategies to navigate through the grieving process. Therapeutic interventions can help the nurse process the emotions associated with the loss and provide a safe space to express and explore feelings of grief and loss.
Options A, C, and D may be helpful in certain situations, but they may not directly address the nurse's unresolved grief:
A. Taking a leave of absence to pursue healing can be considered if the nurse's grief is severely impacting their ability to function and provide safe patient care. However, it may not be necessary for everyone, and seeking therapy would be a more specific and targeted approach to address the grief.
C. Using stress reduction strategies can be beneficial for managing stress and promoting overall well-being, but it may not directly address the specific grief experienced by the nurse after the client's death.
D. Seeking an informal forum for discussing death can be helpful in processing feelings and emotions related to death and loss. However, it may not provide the level of support and guidance that therapy can offer in resolving grief.
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