An older client is admitted to an acute care facility with the diagnosis of left lower lobe pneumonia. How should the practical nurse (PN) position the client for auscultation of posterior lung fields?
Lateral, semi-prone.
Semi-Fowler's.
Right side-lying.
Forward orthopneic.
The Correct Answer is A
Choice B rationale:
The semi-Fowler's position involves elevating the head of the bed to 30-45 degrees, which is useful for clients with respiratory issues to promote lung expansion. However, for auscultation of the posterior lung fields in a client with left lower lobe pneumonia, the lateral, semi-prone position is more appropriate as it allows better access to the specific area of concern.
Choice C rationale:
Placing the client on the right side-lying position may not be as effective for auscultating the left lower lobe, as the target area is located on the opposite side. The lateral, semi-prone position offers better access to the left lower lobe for assessment.
Choice D rationale:
The forward orthopneic position is a sitting position with the arms supported on a table or over the bed. While this position can assist clients with breathing difficulties, it is not suitable for auscultation of the posterior lung fields. The lateral, semi-prone position is more appropriate for this purpose.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
This is the best action for the PN to take because it provides immediate relief for the client's pain, which can be severe and debilitating in Herpes zoster. The PN should also assess the client's pain level, location, and characteristics and document the response to the medication.
Correct Answer is B
Explanation
The correct answer isChoice B.
Choice B rationale:
The practical nurse (PN) should instruct the unlicensed assistive personnel (UAP) to keep the client's skin clean and dry. Proper skin care is essential for a client with urinary and fecal incontinence to prevent the development of pressure ulcers. Keeping the skin clean and dry helps reduce moisture-related skin breakdown.
Choice A rationale:
Encouraging the client to rest quietly in bed is not directly related to preventing pressure ulcers. While adequate rest is essential for overall health, it does not specifically address the risk of pressure ulcers in an incontinent client.
Choice C rationale:
Obtaining supplies for contact precautions is unrelated to the client's risk of developing a sacral pressure ulcer. Contact precautions are used to prevent the spread of infectious diseases and do not address skin integrity.
Choice D rationale:
Documenting any changes in skin integrity is important, but it is the responsibility of the healthcare team, including the PN. However, this response does not provide proactive measures to prevent the pressure ulcer from occurring in the first place, which is the primary concern in this situation.
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