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 B
Explanation
Choice A rationale:
While measuring urinary output is an important nursing intervention, it may not be the most critical action for a client with left-sided heart failure. Left-sided heart failure primarily affectspulmonary circulation, and assessing lung sounds is a priority in this situation.
Choice C rationale:
Checking mental acuity is a valid nursing intervention, but it may not be the most crucial action for a client with left-sided heart failure. The priority in this case is to monitor respiratory status and identify any signs of respiratory distress.
Choice D rationale:
Inspecting for sacral edema is also a relevant nursing intervention, as it can indicate fluid retention in heart failure patients. However, auscultating the lung fields takes precedence in this scenario to assess for signs of pulmonary congestion, which is a common complication of left-sided heart failure.
Correct Answer is B
Explanation
Correct Answer: B. Joint pain.
Choice B rationale:
Joint pain is the most common symptom experienced by individuals during a sickle cell crisis. The misshapen red blood cells can block blood flow to joints, leading to severe pain and inflammation. Joint pain is a hallmark sign of a sickle cell crisis, and managing pain is a critical aspect of caring for these patients.
Choice A rationale:
Decreased hemoglobin is not the expected symptom during a sickle cell crisis. A sickle cell crisis is characterized by sudden and severe pain due to the misshapen red blood cells blocking blood flow and causing tissue damage. While a sickle cell crisis can lead to anemia, the child experiencing the crisis would be more likely to describe pain and not specifically mention decreased hemoglobin.
Choice C rationale:
Infection is not a typical symptom experienced during a sickle cell crisis. While sickle cell disease can increase the risk of infections, the crisis itself primarily manifests as acute pain due to vaso-occlusion.
Choice D rationale:
Fatigue may be experienced by individuals with sickle cell disease, especially during or after a crisis, but it is not the most likely symptom they would describe during a sickle cell crisis. The hallmark symptom of a sickle cell crisis is severe pain.
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