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 D

Explanation

Dry mucous membranes and a dry mouth are common side effects of anticholinergic drugs like dicyclomine. These medications block the action of acetylcholine, a neurotransmitter responsible for stimulating secretions in the body. As a result, the client may experience dryness in various parts of the body, including the mouth.
Providing oral care, such as offering the client sips of water or providing a moistening agent for the mouth, can help alleviate the discomfort caused by dryness and promote oral hygiene. It is an appropriate and immediate intervention for the client's current symptoms.
Incorrect:
A. Checking vital signs may not directly address the client's dry mouth, but it is a good practice to assess the client's overall condition.
B. Monitoring hemoglobin would not be necessary in this situation, as it does not directly relate to the client's dry mucous membranes.
C. Notifying the charge nurse may be appropriate if the client's symptoms worsen or if there are other concerning factors, but the priority action in this case is to provide oral care to address the client's discomfort.

A. "It's okay if you don't want to look or talk about the mastectomy. It will be available when you're ready." B. "Would you like me to call another nurse to be here while I show you the wound?" C. "Part of recovery is accepting your new body image, and you will need to look at your incision." D. "You will feel better when you see that the incision is not as bad as you may think."

Correct Answer is A

Explanation

When a client refuses to look at their mastectomy incision and refuses to talk about it, the best response by the practical nurse (PN) is to respect the client's autonomy and validate their feelings. Option a) acknowledges the client's discomfort and provides reassurance that it is okay for them to decline to look or talk about the incision at the moment. It also oﬀers support by letting the client know that the incision will be available for examination when they feel ready to do so.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with irritable bowel syndrome (IBS) is receiving dicyclomine, an anticholinergic drug. Prior to administering the next dose, the practical nurse (PN) determines that the client's mucous membranes are dry, and the client reports having a dry mouth. Which action should the PN take

Correct Answer is D

Explanation

At the first dressing change, the practical nurse (PN) tells the client that her mastectomy incision is healing well, but the client refuses to look at the incision and refuses to talk about it. Which response by the PN to the client's silence is best?

Correct Answer is A

Explanation

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