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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.6"]
Explanation
Step 1: Determine the dosage available per mL.
- Available dosage is 8 mg in 0.4 mL.
- Calculation: 8 mg ÷ 0.4 mL = 20 mg/mL.
- Result: 20 mg/mL.
Step 2: Calculate the volume needed for 12 mg.
- Required dosage is 12 mg.
- Calculation: 12 mg ÷ 20 mg/mL = 0.6 mL.
- Result: 0.6 mL.
So, the nurse should administer 0.6 mL of methylnaltrexone.
Correct Answer is ["B","C","D"]
Explanation
Complicated grieving, also known as complicated grief or prolonged grief disorder, refers to a type of grief that is prolonged, intense and does not follow the typical trajectory of mourning. It can manifest differently in different individuals, but some common signs of complicated grieving include:
B. An adult who insisted for many years that the adult hated the adult's deceased parent: This could indicate unresolved emotional conflicts with the deceased parent, which may be contributing to complicated grief.
C. The parent of a child who died after having left the child in a car on a hot day: This situation involves feelings of guilt and responsibility, which can complicate the grieving process.
D. The grandchild of a soldier killed in war who visits the grave once a year on Memorial Day: This response is likely a normal grief response, as the person visits the grave once a year during Memorial Day, which is a common time for remembering and honoring deceased loved ones.
The following options are not necessarily indicative of complicated grieving:
A. A driver whose spouse and children all died as a result of his driving drunk: While this is undoubtedly a traumatic event, the description provided does not necessarily indicate complicated grieving specifically.
E. The spouse of a person who died 7 years ago and visits the grave several times a day: Visiting the grave several times a day might indicate a deep sense of loss, but it is not specific to complicated grieving and can vary depending on cultural practices and individual coping mechanisms.
It's essential to recognize that grief is a complex and individual process, and professional assessment and support are often required to identify and address complicated grieving in a person.
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