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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["D","F","G"]
Explanation
Based on the provided information, the following components should be included in the treatment regimen for this client:
- Oral anti-diabetic:
While oral medications are common in managing type 2 diabetes, the current information does not suggest immediate initiation of pharmacotherapy based solely on the random blood sugar result without further evaluation.
- Weight-reduction treatment: With a BMI of 28, the client is considered overweight. Weight reduction is an important aspect of managing diabetes and improving overall health. The treatment regimen should include strategies to promote weight loss, such as dietary modifications and increased physical activity.
- Exercise planning: Regular exercise is beneficial for managing diabetes and promoting overall health. The treatment regimen should include an exercise plan tailored to the client's abilities and preferences. This may involve aerobic exercises, strength training, and flexibility exercises.
- Nutrition education: Nutrition plays a crucial role in diabetes management. The client should receive education on healthy eating habits, portion control, carbohydrate counting, and the importance of a balanced diet. The treatment regimen should include ongoing nutrition education and support.
The following options should not be included in the treatment regimen for this client:
- Short-acting insulin: Based on the information provided, there is no indication for the immediate use of short-acting insulin in this client.
- Long-acting insulin: Similar to short-acting insulin, there is no indication for the immediate use of long-acting insulin in this client.
- Extra carbohydrates: Extra carbohydrates may not be necessary for this client unless prescribed by a healthcare professional to manage hypoglycemia or specific dietary needs.
Correct Answer is D
Explanation
Moving the client away from the stimuli in the dayroom and providing a calm environment, it may help to de-escalate the situation and reduce agitation. This action prioritizes the well-being of the client and helps to maintain a safe and therapeutic environment for all individuals involved.
A. Administer an as-needed (PRN) medication for agitation: Administering medication should not be the first action taken in this situation. It is important to first assess the client's condition and attempt to de-escalate the situation through non-pharmacological means. Medication should be considered if other interventions are ineffective or if there is an immediate risk of harm to the client or others.
B. Notify the client's healthcare provider: While it may be necessary to notify the client's healthcare provider about the situation, it is not the first action that should be implemented. The immediate priority is to ensure the safety of the client and those around them by providing support and supervision.
C. Escort the client to a calm and quiet place: Escorting the client to a calm and quiet place can be a helpful intervention, but it may not be the first action to take. It is important to first address the immediate safety concerns and attempt to de-escalate the situation. Once the client is calm and cooperative, they can be escorted to a more suitable environment if necessary.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.