A nurse is assessing a client who has pneumonia. Which of the following manifestations should the nurse expect?
Crackles.
Crepitus.
Stridor.
Decreased fremitus.
The Correct Answer is A
Choice A rationale:
Crackles are adventitious lung sounds that can be heard on auscultation and are commonly associated with pneumonia. They are caused by the movement of air through fluid-filled or collapsed alveoli, indicating inflammation and infection in the lungs.
Choice B rationale:
Crepitus is a different respiratory finding and is not typically associated with pneumonia. Crepitus is a crackling or grating sensation that can be felt under the skin, often caused by subcutaneous emphysema or gas trapped in the tissues, not within the lungs.
Choice C rationale:
Stridor is a harsh, high-pitched sound heard during inspiration and is usually indicative of upper airway obstruction, not pneumonia. It can be caused by conditions such as croup or anaphylaxis.
Choice D rationale:
Decreased fremitus is not a specific manifestation of pneumonia. Fremitus is the vibration felt when the patient speaks and is transmitted through the chest wall. In pneumonia, increased fremitus may be observed due to the consolidation of lung tissue with fluid or pus, not decreased fremitus.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
Choice A rationale:
The nurse should administer oxygen to the client experiencing a sickle cell crisis. Sickle cell crisis can cause vaso-occlusion, leading to tissue hypoxia and pain. Administering oxygen helps to improve tissue oxygenation and relieve symptoms.
Choice B rationale:
Administering opioids is appropriate for managing the severe pain associated with a sickle cell crisis. Opioids are effective analgesics that can help alleviate the acute pain experienced by the client.
Choice C rationale:
Administering whole blood is not typically indicated for a sickle cell crisis. Whole blood transfusion is reserved for specific indications, such as severe anemia or acute blood loss, but it is not a standard treatment for sickle cell crisis pain.
Choice D rationale:
Elevating the head of the bed to 30° can improve oxygenation and reduce the workload on the respiratory system, which is beneficial for clients experiencing a sickle cell crisis. It helps to optimize lung expansion and alleviate hypoxia.
Choice E rationale:
Keeping the client NPO (nothing by mouth) is not necessary in a sickle cell crisis. There is no indication that the client cannot tolerate oral intake, so allowing them to eat and drink as usual is appropriate.
Correct Answer is D
Explanation
Choice A rationale:
Instructing the client to take deep breaths during the test is not appropriate for a thoracentesis. This procedure involves the insertion of a needle into the pleural space to drain fluid or air, and taking deep breaths could interfere with the accuracy and safety of the procedure.
Choice B rationale:
Assisting the client to a prone position prior to the test is also incorrect. During a thoracentesis, the client is usually seated upright or in a slightly forward-leaning position to allow better access to the pleural space and improve breathing.
Choice C rationale:
Informing the client that the new onset of a cough is expected following the test is not accurate. While a cough can be a possible side effect, it is not a common or expected outcome of a thoracentesis.
Choice D rationale:
Applying pressure to the client's puncture site after the test is complete is the correct action. This helps to prevent bleeding and reduce the risk of pneumothorax (collapsed lung) by promoting clot formation at the site of the needle insertion.
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