A nurse is auscultating a client’s lung sounds and identifies crackles in the left lower lobe. Which intervention should the nurse take first?
Repeat auscultation after asking the client to take a deep breath and cough.
Instruct the client to limit fluid intake to less than 2,000 mL/day.
Place the client on bed rest in semi-Fowler’s position.
Prepare to administer antibiotics.
The Correct Answer is A
Choice A Reason:
Repeating auscultation after asking the client to take a deep breath and cough is the first intervention the nurse should take. This action helps to clear any secretions or mucus that might be causing the crackles. If the crackles persist after the client coughs, it indicates that the sounds are likely due to fluid in the lungs, which requires further assessment and intervention. This step ensures that the nurse accurately identifies the cause of the crackles before proceeding with other interventions.
Choice B Reason:
Instructing the client to limit fluid intake to less than 2,000 mL/day might be appropriate in cases of fluid overload or heart failure, but it is not the first intervention. The nurse needs to confirm the cause of the crackles before making any recommendations about fluid intake. Limiting fluid intake without proper assessment could lead to dehydration and other complications.
Choice C Reason:
Placing the client on bed rest in semi-Fowler’s position can help improve lung expansion and oxygenation by reducing pressure on the diaphragm. However, this is not the first intervention. The nurse should first determine if the crackles are due to secretions that can be cleared by coughing. Semi-Fowler’s position is beneficial for patients with respiratory distress, but it does not address the immediate need to reassess lung sounds.
Choice D Reason:
Preparing to administer antibiotics is not the first intervention. Antibiotics are used to treat infections, and the nurse needs to confirm whether the crackles are due to an infection or another cause before administering medication. Immediate administration of antibiotics without proper assessment could lead to inappropriate treatment and antibiotic resistance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: A history of hypothyroidism is not a contraindication for magnet therapy. Hypothyroidism is a condition where the thyroid gland does not produce enough thyroid hormone, but it does not interfere with the use of magnetic fields. Therefore, patients with hypothyroidism can safely use magnet therapy.
Choice B reason: Having a pacemaker is a significant contraindication for magnet therapy. Magnetic fields can interfere with the functioning of pacemakers, potentially leading to serious complications. Patients with pacemakers should avoid magnet therapy to prevent any risk of device malfunction.
Choice C reason: A history of narcolepsy is not a contraindication for magnet therapy. Narcolepsy is a neurological disorder that affects the control of sleep and wakefulness, but it does not interact with magnetic fields. Therefore, patients with narcolepsy can use magnet therapy without concern.
Choice D reason: An indwelling catheter is not a contraindication for magnet therapy. Indwelling catheters are used for urinary drainage and do not interact with magnetic fields4. Patients with indwelling catheters can safely undergo magnet therapy.
Correct Answer is B
Explanation
Choice A Reason:
Securing the oxygen tubing to the bed sheet near the client’s head is not recommended because it can lead to accidental dislodgement of the tubing, which can interrupt the oxygen supply. Additionally, this practice does not address the potential for nasal dryness and irritation that can occur with oxygen therapy. Properly securing the tubing should involve ensuring it is comfortably positioned and not at risk of being pulled or dislodged.
Choice B Reason:
Attaching a humidifier bottle to the base of the flow meter is the correct action because it helps to add moisture to the oxygen being delivered to the client. Oxygen therapy, especially at higher flow rates like 5 L/min, can dry out the nasal passages and mucous membranes, leading to discomfort and potential complications. The humidifier bottle ensures that the oxygen is humidified, which helps to prevent dryness and irritation, making the therapy more comfortable and effective for the client.
Choice C Reason:
Applying petroleum jelly to the nares is not recommended because petroleum-based products can be flammable and pose a risk when used in conjunction with oxygen therapy. Additionally, petroleum jelly can trap bacteria and potentially lead to infections. Instead, water-based lubricants or saline nasal sprays are safer alternatives for soothing dry nasal passages.
Choice D Reason:
Removing the nasal cannula while the client eats is not advisable because it interrupts the continuous delivery of oxygen, which is essential for clients with pneumonia who may already have compromised respiratory function. Instead, the nurse should ensure that the nasal cannula is securely in place and that the client is receiving the prescribed oxygen therapy at all times, including during meals.
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