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.
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Naxlex Comprehensive Predictor Exams
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Correct Answer is D
No explanation
Correct Answer is A
Explanation
A. Washing the hair and skin daily with mild soap and warm water helps remove excess oil, dirt, and bacteria that can contribute to acne formation. Gentle cleansing is an appropriate first-line recommendation for adolescents with mild acne.
B. Eliminating specific foods such as chocolate or fried foods is not consistently supported by evidence as a primary treatment for acne. Diet may influence some individuals, but routine restriction of these foods is not a standard initial recommendation.
C. Squeezing or expressing blackheads can traumatize the skin, increase inflammation, and lead to scarring or infection. Harsh exfoliation may further irritate the skin and worsen acne.
D. Referral to a dermatologist may be necessary for severe or persistent acne. However, initial management for mild acne typically includes proper skin hygiene and over-the-counter measures before pursuing long-term prescription therapy.
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