The practical nurse (PN) heard adventitious breath sounds while auscultating the lungs of an older adult who is receiving an IV of 5% dextrose in water (DW) at 100 mL/hour. Which action should the PN take next?
Report the findings to the charge nurse.
Review the last balance of intake and output.
Slow the DSW infusion rate to 50 ml/hour.
Document the findings and monitor the client.
The Correct Answer is A
The practical nurse (PN) who hears adventitious breath sounds while auscultating the lungs of an older adult who is receiving an IV of 5% dextrose in water (DW) at 100 mL/hour should report the findings to the charge nurse.
Adventitious breath sounds can be indicative of respiratory problems such as fluid accumulation or infection in the lungs. In this case, it is important for the PN to report the findings to the charge nurse to ensure appropriate action is taken to assess and manage the client's respiratory status.
incorrect:
B- Reviewing the last balance of intake and output is important for overall assessment but may not directly address the concern of adventitious breath sounds. It can provide additional information about the client's fluid balance, but it is not the next immediate action in response to the abnormal lung sounds.
C- Slowing the DSW infusion rate to 50 mL/hour is not the most appropriate action to take based solely on the presence of adventitious breath sounds. The abnormal lung sounds may be an indication of an underlying respiratory issue that needs further evaluation and intervention.
Adjusting the infusion rate without a comprehensive assessment and appropriate medical orders could potentially overlook the underlying cause.
D- Documenting the findings and monitoring the client is necessary, but it should not be the sole action taken. Reporting the findings to the charge nurse is crucial to ensure prompt assessment and appropriate intervention.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Worsening perineal pain after medication could indicate inadequate pain relief or a potential complication such as infection or hematoma. It is important to reassess the client to determine the cause of the increased pain and take appropriate action before transferring to the postpartum unit.
The other scenarios described in the options may also require attention, but they do not indicate an immediate need for reassessment before transfer:
B. A primigravida who passed a small clot when she sat up on the edge of the bed: Passing small clots is a normal part of the postpartum period, and it may not necessarily require immediate reassessment. However, the PN should monitor for any excessive or large clots and report any concerning findings.
C. A multigravida whose peri-pad is 1⁄2 saturated with lochia rubra after one hour: Lochia rubra is the normal discharge following childbirth, and some saturation of the peri-pad is expected.
However, the PN should continue to monitor the amount and consistency of the lochia and report any significant changes.
D. A multigravida complaining of strong afterbirth pains when breastfeeding: Afterbirth pains, also known as uterine cramps, are common during breastfeeding as the uterus contracts. While discomfort is expected, strong afterbirth pains should be assessed for severity and managed appropriately. The PN should provide comfort measures and assess if the pain is within the expected range or if it requires further evaluation.
Correct Answer is D
Explanation
When providing instructions to a client with a below-the-knee cast for a compound fracture of the left ankle, it is important to prioritize their safety and proper care of the cast. The instruction to never scratch under the cast is crucial for preventing complications and maintaining the integrity of the cast.
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