The home care nurse visits a client with compromised lung function. The client has greenish yellow sputum with a musty odor. Which assessment is the priority for the

Auscultate bilateral breath sounds.

Obtain blood culture for tuberculosis.

Request pulmonary function studies.

Document the findings.

Answer and Explanation

The Correct Answer is A

The client's greenish-yellow sputum with a musty odor may indicate an infection, such as pneumonia or bronchitis, which can aﬀect the client's lung function. By auscultating bilateral breath sounds, the nurse can assess for the presence of abnormal lung sounds, such as crackles or wheezing, which may indicate further respiratory compromise.

While obtaining a blood culture for tuberculosis (option b) may be appropriate in certain circumstances, the client's sputum color and odor do not necessarily indicate tuberculosis as the cause of their respiratory symptoms.

Requesting pulmonary function studies (option c) may also be beneficial in assessing the client's lung function, but this is not the priority assessment in this situation.

Finally, while documenting the findings (option d) is an important aspect of nursing care, it is not the priority action when the client is presenting with signs of compromised lung function.

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Correct Answer is A

Explanation

The use of an incentive spirometer is essential after surgery to prevent complications such as pneumonia and atelectasis. Atelectasis is the collapse of air sacs in the lungs, which can occur after surgery due to decreased respiratory eﬀort and shallow breathing. An incentive spirometer helps the patient take deep breaths and increase their lung volume, preventing these complications.

Breathing rapidly to prevent pneumonia (option b) is not recommended as it can lead to hyperventilation and other respiratory complications.

Option c is incorrect because patient education is a crucial aspect of post-operative care, and the patient needs to be aware of the potential complications and how to prevent them.

The use of a chest tube (option d) is not usually required after hip surgery, and it is not a priority teaching for the patient.

A. The chest tube drainage system should be placed on the bedside table. B. The chest tube drainage system should be placed on the bed near the patient. C. The chest tube drainage system must be placed below the site of insertion. D. The chest tube drainage system should be placed on the siderail near the patient.

Correct Answer is C

Explanation

: Chest tube placement is done to remove air or ﬂuid from the pleural space, which is the area between the lungs and the chest wall. The chest tube drainage system is an important tool to monitor and manage the drainage from the chest tube.

It is essential that the chest tube drainage system is placed below the level of the patient's chest and the site of insertion. This is necessary to create a continuous drainage system by allowing gravity to assist in the ﬂow of air or ﬂuid out of the pleural space. If the chest tube drainage system is placed above the insertion site, the ﬂuid will not drain properly, which can cause the ﬂuid to back up into the patient's chest cavity, leading to complications such as pneumothorax or hemothorax.

Therefore, the appropriate statement regarding a chest tube is that the chest tube drainage system must be placed below the site of insertion.

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The home care nurse visits a client with compromised lung function. The client has greenish yellow sputum with a musty odor. Which assessment is the priority for the

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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