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","D","E"]

Explanation

Since the pregnant woman is vegetarian and does not eat meat, the practical nurse (PN) should provide alternative sources of iron-rich foods. Lentils and black beans are excellent vegetarian sources of iron and can be added to soups to increase iron intake (option a).

Oatmeal is a good choice for breakfast as it is often fortified with iron (option d). This can help supplement iron intake in the diet.

Green leafy vegetables, such as spinach, kale, and broccoli, are also rich in iron and should be increased in the client's diet (option e).

Option b, which suggests eating red meat just until the anemia is resolved, is not appropriate for a vegetarian client.

Option c, taking two prenatal vitamins with iron daily, is not necessary unless specifically advised by the healthcare provider. It is important to follow the prescribed dosage of medication and supplements as directed by the healthcare provider.

A. Ask to see the client's list of home medications B. Determine if the client has recently lost a loved one C. Measure the client's vital signs D. Collect a sputum and urine culture and sensitivities E. Perform a 12-lead electrocardiogram F. Have the client ambulate across the room. G. Ask about the client's last bowel movement H. Measure the client's abdominal circumference

Correct Answer is ["A","B","C","E","H"]

Explanation

To identify the potential source of the client's new-onset confusion and decreased appetite, the nurse can use the following assessment techniques:

Ask to see the client's list of home medications: This can help identify any medications that may contribute to confusion or appetite changes.
Determine if the client has recently lost a loved one: Emotional distress, such as grief from a recent loss, can contribute to changes in mental status and appetite.
Measure the client's vital signs: Vital signs can provide important information about the client's overall health status and help identify any abnormalities that may be contributing to the symptoms.
Perform a 12-lead electrocardiogram: This can help assess the client's cardiac function and detect any cardiac-related causes for the symptoms.
Ask about the client's last bowel movement: Changes in bowel habits can sometimes be indicative of underlying issues affecting appetite and overall health.
Measure the client's abdominal circumference: This can help assess for any abdominal distension or changes that may be related to the client's symptoms.

Collecting a sputum and urine culture and sensitivities and having the client ambulate across the room are not directly related to identifying the potential source of confusion and decreased appetite in this case.

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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

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

Explanation

Exhibits here Review H and P and nurse's notes. What other assessment techniques can the nurse use to identify the potential source of the client's new-onset confusion and decreased appetite? Select all that apply.

Correct Answer is ["A","B","C","E","H"]

Explanation

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