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 D
A- Positioning in semi-Fowler’s can aid breathing but doesn’t assess crackles’ cause. It’s supportive, not diagnostic, and premature without further data
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- Reassessing after deep breathing and coughing evaluates secretion clearance, aligning with nursing assessment and Maslow’s physiological needs
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["2"]
Explanation
To calculate the amount of naloxone to administer, you can use the following formula:
Amount to administer (mL) = Total dose required (mg) / Concentration of drug (mg/mL)
Given:
Total dose required = 0.4 mg
Concentration of drug = 0.2 mg/mL
Let's calculate the amount to administer:
Amount to administer (mL) = 0.4 mg / 0.2 mg/mL
Now, perform the calculation:
Amount to administer (mL) = 2 mL
So, the nurse should administer 2 mL of naloxone intravenously as a bolus dose to the client.
Correct Answer is A
Explanation
Anticipatory grief refers to the emotional response and mourning that occurs before an actual loss or death. In this case, the client is grieving the loss of the pregnancy due to the decision to have an elective abortion. The grief arises from the anticipation of not being able to have the child at this time, even though they may want to have children in the future.
B- Disenfranchised grief: Disenfranchised grief refers to a type of grief that is not openly acknowledged or socially validated. It occurs when a person experiences a loss that is not commonly recognized or is not socially accepted. In this case, the client's grief is not disenfranchised because the loss of an unintended pregnancy through elective abortion is openly acknowledged and socially accepted.
C- Complicated grief: Complicated grief, also known as prolonged grief or unresolved grief, occurs when a person experiences intense, prolonged, or incapacitating grief that doesn't seem to improve over time. It can be a result of traumatic loss or when the person has difficulty accepting the reality of the loss. The client's grief over the elective abortion does not necessarily indicate complicated grief since it is a normal response to the loss of the pregnancy.
D- Absence of grief: Absence of grief would mean that the client is not experiencing any emotional response or sorrow after the elective abortion, which is unlikely in this situation. The client is crying and expressing emotions, indicating the presence of grief.
In summary, the most appropriate choice for the client's experience is "Anticipatory grief" since the client is grieving the loss of the pregnancy before it actually occurred due to the timing of the pregnancy not aligning with their plans.
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