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.

Answer and Explanation

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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Correct Answer is C

Explanation

The client finding that necessitates immediate attention by the practical nurse (PN) is a client who is having bright red drainage from the rectum following a colonoscopy with polyp removal. Bright red rectal bleeding can indicate active bleeding and immediate intervention is required to assess the severity of the bleeding, control the bleeding if possible, and prevent further complications.
A. The older client with a blood pressure of 100/70 after receiving meperidine for pain may require further assessment, but it does not indicate an immediate life-threatening condition.
B. Pink urine draining from the indwelling urinary catheter following a transurethral prostatectomy may be expected due to the surgical procedure, but it should still be monitored.
D. Brown-green bile draining from a T-tube after cholecystectomy for cholelithiasis is also an expected finding.

A. Consult with the charge nurse about implementing suicide precautions. B. Sit quietly in the client's room until the client is ready to verbalize his feelings. C. Notify a member of the client's family of the need to come stay with the client. D. Leave the room after oﬀering to return to the client's room at a later time. E. Leave the room after oﬀering to return to the client's room at a later time.

Correct Answer is D

Explanation

This is the action that the PN should implement for a male client who has just been told he has cancer and asks to be left alone. Leaving the room after oﬀering to return later respects the client's autonomy and privacy, while also showing empathy and availability. The client may need some time and space to process the diagnosis and cope with his emotions. The PN should not force the client to talk or stay with him if he does not want to, but should also not abandon him or ignore his needs.

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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?

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Naxlex Comprehensive Predictor Exams

After the change-of-shift report, the practical nurse (PN) makes rounds on a postoperative unit. Which client finding necessitates the Immediate attention of the PN?

Correct Answer is C

Explanation

A male client who has just been told he has cancer asks the practical nurse (PN) to leave his room so he can be alone. Which action should the PN implement?

Correct Answer is D

Explanation

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