A nurse is examining the chest of a post-operative client. Upon palpation, the nurse notes a crackling sensation. Which of the following conditions would the nurse report to the provider?
Decreased tactile fremitus.
Pleural friction fremitus.
Crepitus.
Rhonchal fremitus.
The Correct Answer is C
Choice A rationale:
Decreased tactile fremitus refers to a decreased vibration felt upon palpation of the chest, which might be indicative of conditions such as pleural effusion or pneumothorax. It is not directly associated with a crackling sensation.
Choice B rationale:
Pleural friction fremitus occurs when inflamed pleural surfaces rub against each other during breathing. It typically results in a grating sensation rather than a crackling sensation. It is associated with conditions like pleuritis.
Choice C rationale:
(Correct Choice) Crepitus refers to a crackling or grating sound/sensation that occurs when gas or air accumulates in the subcutaneous tissue. It can indicate a serious condition, such as subcutaneous emphysema, which might result from lung or chest wall injury, infections, or surgery.
Choice D rationale:
Rhonchal fremitus is associated with coarse breath sounds caused by thick secretions in the larger airways. It is felt as vibration during palpation and is not related to crackling sensations.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Washing hands for 5 to 10 seconds prior to administering medication is indeed an important safety measure, but it is not specifically related to changing or applying a transdermal patch. Hand hygiene is crucial to prevent the spread of infection, but it doesn't directly address the process of applying a patch.
Choice B rationale:
Applying the patch over a non-hairy area within the patient's skin is the correct answer. This is crucial because hair can interfere with the adhesion of the patch, leading to inadequate drug absorption. The rationale behind this is to ensure that the medication is effectively delivered through the skin into the bloodstream without any barriers such as hair. It's also important to choose a site that is clean, dry, and free from cuts or irritation.
Choice C rationale:
Leaving the previous medication patch in place is not recommended. It's essential to remove the old patch before applying a new one to prevent accumulation of the medication and to ensure accurate dosing. Failing to remove the previous patch could lead to an overdose or altered drug effects.
Choice D rationale:
Ensuring that the patient is lying down is not a specific safety measure for changing or applying a transdermal patch. The patient's position doesn't directly impact the effectiveness of the patch or the safety of the application process.
Correct Answer is C
Explanation
Choice A rationale:
Encouraging the client to ambulate frequently is important for preventing complications associated with immobility, such as deep vein thrombosis and muscle atrophy. However, it is not a direct intervention for promoting the thinning of respiratory secretions.
Choice B rationale:
Encouraging the client to increase fluid intake is a valuable intervention to help thin respiratory secretions. However, the most effective method mentioned here is the use of the incentive spirometer, which directly assists the client in taking deep breaths and enhancing lung function.
Choice C rationale:
Encouraging regular use of the incentive spirometer is a crucial intervention for promoting the thinning of respiratory secretions. Incentive spirometry helps prevent atelectasis (collapse of lung tissue) and promotes deep breathing, which aids in clearing secretions and maintaining lung health.
Choice D rationale:
Encouraging coughing and deep breathing is generally important for maintaining lung health and preventing complications like pneumonia. However, the specific action of using the incentive spirometer is more targeted and effective for promoting respiratory secretion clearance in clients with pneumonia.
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