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
Explanation
Choice A rationale:
The nurse should instruct the client to place cellular phones on the ear opposite the side of the pacemaker to minimize the risk of electromagnetic interference. Although the risk of interference is low with modern pacemakers, it is still a precautionary measure. Placing the phone on the ear opposite the pacemaker reduces the likelihood of any potential electromagnetic interaction.
Choice B rationale:
The instruction in choice B, "Avoid showering for the first 2 weeks following surgery,”. is not appropriate. There is no need for the client to avoid showering after pacemaker insertion. In fact, maintaining good hygiene is essential to prevent infection at the incision site. The client can take a shower, but they should avoid soaking the incision area and patting it dry afterward.
Choice C rationale:
The instruction in choice C, "Avoid heavy lifting for 1 week following insertion,”. is not the best option. The recommended timeframe to avoid heavy lifting after a pacemaker insertion is usually around 4 to 6 weeks. This duration allows the surgical site to heal properly and reduces the risk of dislodging the pacemaker leads or causing damage.
Choice D rationale:
The instruction in choice D, "Stand at least 2 feet away while using a microwave,”. is not directly related to pacemaker care. While it is generally recommended to maintain a safe distance from microwaves during use, this instruction is not specific to clients with pacemakers.
Correct Answer is B
Explanation
Choice A rationale:
Scheduling the client for the last surgery of the day is not directly related to the client's latex allergy. Proper planning for surgery in a latex-allergic client involves addressing potential exposures to latex-containing products and minimizing the risk of allergic reactions.
Choice B rationale:
Placing monitoring cords and tubes in a stockinette can help create a barrier between the client's skin and the latex-containing products. This measure helps reduce the risk of direct contact with latex, which could trigger an allergic reaction in a latex-sensitive individual.
Choice C rationale:
Choosing rubber injection ports for fluid administration is not appropriate for a client with a latex allergy. Rubber products often contain latex, which can lead to an allergic reaction in susceptible individuals.
Choice D rationale:
Having phenytoin IV readily available is not directly relevant to a client with a latex allergy. Phenytoin is an antiepileptic medication and should be available for clients who require it, but it does not address the specific concern of latex exposure.
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