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: Metabolic acidosis is characterized by a decrease in blood pH due to an accumulation of acids or a loss of bicarbonate. It can result from conditions such as diabetic ketoacidosis, renal failure, or severe diarrhea. However, it is not typically associated with opioid overdose. Opioid overdose primarily affects the respiratory system, leading to hypoventilation and respiratory acidosis.
Choice B reason: Respiratory acidosis occurs when there is an accumulation of carbon dioxide (CO2) in the blood due to hypoventilation. Opioid overdose depresses the central nervous system, leading to decreased respiratory rate and depth, which causes CO2 retention. This results in a decrease in blood pH, leading to respiratory acidosis. Symptoms may include confusion, lethargy, and shortness of breath.
Choice C reason: Respiratory alkalosis is characterized by a decrease in blood CO2 levels due to hyperventilation. It can occur in conditions such as anxiety, fever, or high altitude. Opioid overdose, however, causes hypoventilation rather than hyperventilation, making respiratory alkalosis an unlikely outcome.
Choice D reason: Metabolic alkalosis is characterized by an increase in blood pH due to an accumulation of bicarbonate or a loss of acids. It can result from conditions such as prolonged vomiting, diuretic use, or excessive bicarbonate intake. Opioid overdose does not typically lead to metabolic alkalosis. The primary concern with opioid overdose is respiratory depression and the resulting respiratory acidosis.
Correct Answer is C
Explanation
Choice A Reason:
Hyperkalosis is incorrect. Hyperkalosis refers to an elevated level of potassium in the blood, which is not directly related to the pH level. While hyperkalemia can occur in acidosis, it is not the primary condition indicated by a low pH
Choice B Reason:
Hyponatremia is incorrect. Hyponatremia refers to low sodium levels in the blood. It does not directly affect the pH level and is not indicated by the pH value provided.
Choice C Reason:
Acidosis is correct. The normal pH range for arterial blood is 7.35 to 7.45. A pH of 7.10 is below this range, indicating that the blood is too acidic. This condition is known as acidosis.
Choice D Reason:
Alkalosis is incorrect. Alkalosis refers to a condition where the blood pH is higher than the normal range, indicating that the blood is too basic. A pH of 7.10 is too low, not too high, and therefore indicates acidosis.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today