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 D
Explanation
The correct answer is choice D. Don non-sterile gloves when performing direct care.
Choice A rationale:
Placing a surgical mask on the client during transport is not necessary for preventing the spread of Clostridium difficile. C. difficile is primarily spread through contact with contaminated surfaces and not through airborne transmission.
Choice B rationale:
Keeping the door closed to the client’s room at all times is not required for C. difficile infection. The focus should be on contact precautions rather than airborne precautions.
Choice C rationale:
Wearing a particulate respirator mask is not needed for C. difficile, as it is not an airborne pathogen. Standard contact precautions are sufficient.
Choice D rationale:
Donning non-sterile gloves when performing direct care is essential to prevent the spread of C. difficile. The spores can be transmitted via the hands of healthcare workers, so wearing gloves helps to minimize this risk.
Correct Answer is D
Explanation
This is the best action that describes the responsibility of the PN because it ensures that the client has given informed consent for the invasive examination and that the consent form is valid and documented. The PN should verify that the provider has explained the examination, its risks and benefits, and alternative options to the client and that the client has agreed to proceed.
A. Explaining the examination and asking the client to sign the consent form is not the responsibility of the PN but of the provider who will perform the examination.
B. Obtaining the medical record for the correct signed consent form prior to the examination is not enough to ensure informed consent and may not involve any interaction with the client.
C. Asking if the client understands the exam and why the consent form must be signed is not enough to ensure informed consent and may not address any questions or concerns that the client may have.
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