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

Answer and Explanation

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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Correct Answer is B

Explanation

Explanation: This statement is highly inappropriate and victim-blaming. It implies that the client's clothing choices are somehow responsible for the sexual assault they experienced. Victim-blaming is never acceptable and can be harmful to the survivor, making them feel ashamed and responsible for the actions of the perpetrator. As healthcare professionals, nurses should always respond to victims of sexual assault with empathy, compassion, and without judgment.

The other statements (A, C, and D) are all appropriate and acknowledge the seriousness of the situation:

A. "We need to offer the client emotional support especially when obtaining specimens." Explanation: This statement recognizes the need for emotional support during the examination process, which can be distressing for the survivor. Providing emotional support and ensuring the client's comfort and consent during the examination are crucial aspects of caring for a sexual assault survivor.

C. "The client feels like they won't be believed since there was alcohol involved during the date." Explanation: This statement highlights the survivor's feelings and concerns about being believed due to alcohol involvement. It emphasizes the importance of creating a safe and non-judgmental environment for the client, where they can share their experience and receive appropriate care and support.

D. "When the client said 'stop,' that was enough for the perpetrator to get up and walk away." Explanation: This statement indicates an understanding of the importance of consent and acknowledges that the client's clear expression of refusal should have been respected. Understanding and respecting consent is crucial when discussing cases of sexual assault.

A. I’m mentally healthy, I can solve my own problems." B. "What can I do? My spouse abandoned me C. I can't understand why this happened to me." D. I will find a support group to help me through this."

Correct Answer is D

Explanation

The statement, "I will find a support group to help me through this," indicates that the client's coping skills are adequate. Seeking support from others who have experienced a similar loss can be an effective way to cope with feelings of loneliness and vulnerability after the death of a spouse. Support groups provide a safe and understanding environment where individuals can share their experiences, feelings, and struggles, and receive emotional support from others who can relate to their situation.

Option A suggests an overconfidence in coping skills and may not fully acknowledge the need for external support during a challenging time.

Option B indicates a sense of feeling abandoned, which could be a sign of struggling coping skills.

Option C suggests confusion and difficulty accepting the loss, which may indicate inadequate coping skills at the moment.

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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

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Naxlex Comprehensive Predictor Exams

The nurse is working with another nurse in the emergency department (ED) when a client comes in stating they have been raped during a date. Which statement made by the other nurse privately requires immediate correction?

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Explanation

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Correct Answer is D

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