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 B

Explanation

Hypertonic solutions have a higher concentration of solutes (such as sodium, glucose, or mannitol) than the ﬂuid in the body's cells, causing water to move out of the cells and into the bloodstream. This results in the shrinking of the cells and an increase in extracellular ﬂuid volume.

Examples of hypertonic solutions include 10% dextrose in water (D10W), 3% saline, and 5% dextrose in 0.9% saline.

In contrast, isotonic solutions have the same concentration of solutes as the ﬂuid in the body's cells, and hypotonic solutions have a lower concentration of solutes than the ﬂuid in the body's cells.

Therefore, in this scenario, the nurse should administer a hypertonic solution to the client who requires IV ﬂuids.

A. daily electrolyte monitoring B. daily weights C. output measurements D. daily BUN and serum creatinine monitoring

Correct Answer is B

Explanation

Fluid retention is a common complication in heart failure, and monitoring the client's ﬂuid status is crucial to manage the condition eﬀectively. Daily weights are an essential component of monitoring ﬂuid status and are the most sensitive and practical method to detect changes in the client's ﬂuid status. Weight gain is a reliable indicator of ﬂuid retention, and even small increases in weight can indicate the need for changes in the client's treatment plan.

Although electrolyte monitoring (option a), output measurements (option c), and daily BUN and serum creatinine monitoring (option d) can provide valuable information about the client's ﬂuid status, they are not as sensitive or practical as daily weights. Electrolyte monitoring can help detect changes in ﬂuid balance, but it does not provide a direct indication of ﬂuid status. Output measurements can indicate ﬂuid loss, but they do not provide an accurate assessment of ﬂuid retention. BUN and serum creatinine monitoring can detect changes in renal function, but they are not specific to ﬂuid status.

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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

The nurse is caring for a client who requires IV ﬂuids. which IV ﬂuid type would be considered a hypertonic solution?

Correct Answer is B

Explanation

A client admited with heart failure requires careful monitoring of his ﬂuid status. Which method will provide the nurse with the best indication of the client’s ﬂuid status?

Correct Answer is B

Explanation

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