The nurse hears short, rattling, high-pitched sounds in the lower lobes of a client with pneumonia. Which finding should the nurse document?

Stridor.

Pleural rub.

Wheezing.

Crackles.

Answer and Explanation

The Correct Answer is D

D. The short, rattling, high-pitched sounds heard in the lower lobes of the client with pneumonia are indicative of crackles. Crackles are abnormal respiratory sounds that occur when air moves through fluid or mucus in the small airways or alveoli.

A. Stridor refers to a high-pitched, wheezing sound that occurs during inspiration or expiration and is typically associated with upper airway obstruction, such as in conditions like croup or foreign body aspiration.

B. Pleural rub refers to a grating or rubbing sound heard on auscultation that occurs when inflamed pleural surfaces rub against each other during respiration. It is commonly heard in conditions such as pleurisy or pleural effusion.

C. Wheezing refers to a high-pitched, musical sound heard during expiration that is typically associated with narrowing or obstruction of the airways, as seen in conditions like asthma or chronic obstructive pulmonary disease (COPD).

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Correct Answer is B

Explanation

B. The needle should be inserted with the bevel facing up (visible through the skin). The goal is to deposit the medication into the epidermal layer (not subcutaneous tissue).

A. Massaging the site after injection can cause the medication to spread beyond the intended area, leading to inaccurate results or potential complications.

C. The correct angle for an intradermal injection is 5 to 15-degree angle. This angle allows for proper placement of the medication just below the epidermis.

D. Intradermal injections are usually administered on the forearm or the upper back, where the skin is thin and easily lifted to create a wheal.

A. Remind the client no milk or creamer can be added to the coffee. B. Determine which member of the nursing staff brought the cup of coffee to the client. C. Remove the coffee from the tray, advising the client that it is not included in the diet. D. Consult with the dietitian to learn if the client is allowed to drink coffee.

Correct Answer is C

Explanation

C. A clear liquid diet typically includes transparent or translucent liquids that are easy to digest and leave minimal residue in the gastrointestinal tract. Coffee, especially if it contains milk or creamer, is not considered a clear liquid and is not usually permitted on a clear liquid diet.

A. Reminding the client no milk or creamer can be added to the coffee may be appropriate for clients on other dietary restrictions but does not address the issue of coffee not being part of a clear liquid diet.

B. Determining which member of the nursing staff brought the cup of coffee to the client is not necessary unless there is a need to investigate a specific incident or identify potential lapses in care.

D. Consulting with the dietitian to learn if the client is allowed to drink coffee may be appropriate for clarifying dietary restrictions or allowances, but in the context of a clear liquid diet, coffee is typically not permitted regardless of the dietitian's input.

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The nurse hears short, rattling, high-pitched sounds in the lower lobes of a client with pneumonia. Which finding should the nurse document?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is administering an intradermal (ID) injection to a client. Which action should the nurse take?

Correct Answer is B

Explanation

The nurse observes a client on a clear liquid diet has a cup of coffee on the breakfast tray. Which action should the nurse implement?

Correct Answer is C

Explanation

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