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 D

Explanation

A. Wheezes:

Wheezes are high-pitched, musical sounds that occur during inspiration or expiration and are often associated with narrowed airways, such as in conditions like asthma or chronic obstructive pulmonary disease (COPD).

B. Stridor:

Stridor is a high-pitched, crowing sound that is typically heard during inspiration and can be associated with upper airway obstruction, such as in croup or epiglottitis.

C. Rhonchi:

Rhonchi are low-pitched, snoring or rattling sounds that can occur during inspiration or expiration. They are often associated with the presence of mucus or other airway obstruction and can be heard in conditions like bronchitis or pneumonia.

D. Crackles:

Crackles are bubbling, popping sounds heard during inspiration or expiration. They can be further classified as fine or coarse. Fine crackles are often associated with conditions like pulmonary fibrosis, while coarse crackles can be heard in conditions like congestive heart failure or pneumonia.

A. Performs auscultation between meals B. Clamps the Naso Gastric tube during auscultation C. Palpates the abdomen prior to performing auscultation. D. Auscultates bowel sounds for 3 to 5 min

Correct Answer is C

Explanation

A. Performs auscultation between meals:

Auscultating bowel sounds between meals is suitable as it allows for better detection of bowel sounds when digestion is not actively occurring.

B. Clamps the Naso Gastric tube during auscultation

Clamping the Naso Gastric (NG) tube during auscultation is appropriate. The NG tube when unclamped allows the free passage of air and fluid through the gastrointestinal tract. This could interfere with the natural sounds produced by the movement of air and fluid in the intestines, potentially leading to inaccurate assessment of bowel sounds.

C. Palpates the abdomen prior to performing auscultation:

Palpating the abdomen before auscultation may interfere with normal bowel sounds

D. Auscultates bowel sounds for 3 to 5 min:

Auscultating bowel sounds for a sufficient duration (3 to 5 minutes) is appropriate to comprehensively assess the presence, frequency, and character of bowel sounds.

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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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