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 A

Explanation

A. Gather the procedure tray and equipment – The practical nurse should gather all necessary supplies for the healthcare provider to perform the thoracentesis efficiently. Preparing the equipment beforehand ensures that the procedure can start promptly and reduces interruptions for missing supplies.

Rationale for Incorrect Answers:
B. Cleanse the site and cover with a sterile towel – This action should be performed by the healthcare provider immediately before the procedure to maintain sterility. The PN’s role is to prepare equipment and ensure the client is positioned correctly.

C. Keep the patient NPO (nothing by mouth) and encourage them to void – While voiding may be encouraged before some procedures to improve client comfort, it is not necessary for thoracentesis. Additionally, keeping the client NPO is not required, as the procedure does not typically involve sedation that would necessitate this restriction.

D. Place the patient in an orthopneic position – This may be done just before the procedure, but the healthcare provider typically directs the final positioning. Initial positioning or seating at the bedside can be done, but orthopneic positioning should follow the provider’s instructions.

A. Dim the lights in the room and close the door. B. Turn the television on to the client's favorite show. C. Guide the client through slow, rhythmic breathing. D. Obtain a prescription for a higher dose of pain medication.

Correct Answer is C

Explanation

The best action for the practical nurse (PN) to assist the client in dealing with his pain would be to guide the client through slow, rhythmic breathing.
Guiding the client through slow, rhythmic breathing techniques can help promote relaxation and reduce anxiety, which can indirectly contribute to pain relief. Deep breathing exercises can help the client focus on their breath and divert attention away from the pain, providing some relief and helping them cope with the discomfort. It is a non-pharmacological intervention that can be implemented immediately to help the client manage their pain.
The other options are less effective or not appropriate in this situation:

A. Dimming the lights in the room and closing the door may create a more calming environment, but it does not directly address the client's pain or provide them with effective pain relief.
B. Turning the television on to the client's favorite show may serve as a distraction, but it may not be sufficient to alleviate the client's pain.
D. Obtaining a prescription for a higher dose of pain medication should only be considered after evaluating the client's current pain management regimen and assessing their response to the current medication. It is not the immediate best action to take without further assessment and consideration of other non-pharmacological interventions.

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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

Ancient is scheduled for a thoracentesis that will be done at the bedside. What should the practical nurse (PN) prepare before the healthcare provider arrives to perform the procedure?

Correct Answer is A

Explanation

Correct Answer is C

Explanation

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