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","B","D"]

Explanation

The correct answer is: a. Paper tape, b. Small gauze pad, and d. Exam gloves.

Choice A: Paper tape

Reason: Paper tape is used to secure the gauze pad over the site after the saline lock is removed. It is gentle on the skin and helps to keep the gauze in place, preventing any bleeding or infection at the site.

Choice B: Small gauze pad

Reason: A small gauze pad is essential to apply pressure to the site after the saline lock is removed. This helps to stop any bleeding and provides a clean, sterile covering for the site.

Choice C: Sterile gloves

Reason: Sterile gloves are not necessary for this procedure. Exam gloves are sufficient to maintain cleanliness and prevent infection during the removal of the saline lock.

Choice D: Exam gloves

Reason: Exam gloves are used to maintain hygiene and prevent infection during the procedure. They provide adequate protection for both the nurse and the patient.

Choice E: Three mL syringe

Reason: A three mL syringe is not required for the removal of a saline lock. Syringes are typically used for flushing the saline lock, not for its removal.

A. Remind the client that he is likely to gain weight when attempting to stop smoking. B. Provide information to the client about risks associated with smokeless tobacco. C. Explain to the client that obesity is a more significant health risk than smoking. D. Encourage the client to continue with this plan to reduce his risk for cancer.

Correct Answer is B

Explanation

Smokeless tobacco, such as chewing tobacco or snuff, still contains harmful substances, including nicotine and various chemicals. It is associated with several health risks, including an increased risk of oral, esophageal, and pancreatic cancers, as well as gum disease, tooth loss, and nicotine addiction.
Incorrect:

A. By providing this information, the nurse can help the client make an informed decision about their smoking cessation plan. It is crucial to emphasize that quitting tobacco altogether is the best approach to reduce the risk of cancer and improve overall health.
C. The nurse should not encourage the client to continue with the plan to switch to smokeless tobacco as a means of reducing the risk for cancer. Instead, the focus should be on supporting the client's efforts to quit tobacco entirely and providing appropriate resources and interventions to facilitate smoking cessation.
D. Addressing the concern about weight gain when quitting smoking is also important, but it should be done in the context of promoting healthy lifestyle changes and offering strategies to manage weight during the smoking cessation process.

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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

The practical nurse (PN) prepares to remove a client's saline lock. Which supplies should the PN gather? (Select all that apply.)

Correct Answer is ["A","B","D"]

Explanation

A male client tells the practical nurse (PN) that he is afraid of getting cancer so he plans to quit smoking cigarettes by switching to a smokeless tobacco product. How should the PN respond?

Correct Answer is B

Explanation

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