A nurse is auscultating 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 supine position.

Repeat auscultation after asking the client to breathe deeply and cough.

Prepare to administer antibiotics.

Instruct the client to limit fluid intake to less than 2,000 mL/day.

Answer and Explanation

The Correct Answer is B

A. Place the client on bed rest in supine position:

While bed rest might be appropriate for certain respiratory conditions, it is not a specific intervention for crackles. In fact, changing the client's position, such as having them sit up, may enhance lung function and help with breathing.

B. Repeat auscultation after asking the client to breathe deeply and cough:

This is the correct action. Repeating auscultation after having the client take deep breaths and cough can provide additional information about the nature of the crackles and may help clear the airways temporarily.

C. Prepare to administer antibiotics:

Administering antibiotics would be considered if the crackles are indicative of a respiratory infection. However, determining the need for antibiotics would require a more comprehensive assessment, including diagnostic tests.

D. Instruct the client to limit fluid intake to less than 2,000 mL/day:

Limiting fluid intake is not a direct intervention for crackles. This action is typically considered in conditions like heart failure where there is a risk of fluid overload. It is not the primary intervention for addressing crackles in the lungs.

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Correct Answer is B

Explanation

A. Redo the initial assessment and document current findings:

This option suggests repeating the entire initial assessment. While reassessment is important, redoing the entire initial assessment may not be necessary. Instead, a focused assessment on the specific area of concern (skin integrity) is more appropriate.

B. Perform and document a focused assessment of skin integrity:

This is the recommended choice. If unexpected findings are observed during care, such as reddened areas over bony prominences, it is important to conduct a focused assessment on the skin to identify any issues and document the findings accurately.

C. Correct the initial assessment form:

Simply correcting the initial assessment form may not address the immediate need for assessing and addressing the reddened areas. It is more crucial to perform a focused assessment on the skin.

D. Conduct and document an emergency assessment:

Reddened areas over bony prominences may not necessarily indicate an emergency. However, addressing the issue promptly is important. A focused assessment would be more appropriate than conducting a full emergency assessment.

A. Develop a plan of care for the client B. Provide a schedule of visiting hours to the client’s family C. Teach the client about his diagnosis D. Document the client’s code status

Correct Answer is D

Explanation

A. Develop a plan of care for the client:

Developing a plan of care is essential, but it should be informed by the client's current condition, diagnosis, and code status. Documenting the code status is a foundational step.

B. Provide a schedule of visiting hours to the client’s family:

While facilitating family involvement is important, it is not the top priority during the initial admission assessment. Ensuring the client's safety and understanding their code status takes precedence.

C. Teach the client about his diagnosis:

Patient education is important, but in a critical situation, the priority is to assess and document key information, including the code status. Education can follow once the immediate priorities are addressed.

D. Document the client’s code status

When conducting the initial admission assessment for a critical client, the priority action is to document the client's code status. Code status refers to the set of directives given by the client or their legal representative regarding the use of cardiopulmonary resuscitation (CPR) and other life-sustaining measures in the event of a cardiac or respiratory arrest.

Understanding and documenting the client's code status is crucial for informing the healthcare team about the client's preferences for resuscitation efforts. This information guides the team in providing care that aligns with the client's wishes and values.

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A nurse is auscultating 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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