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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The finding that is the highest priority for the PN to report to the charge nurse is the blood urea nitrogen (BUN) level of 75 mg/dL or 12.9 mmol/L. This result indicates an elevated BUN level, which can be indicative of impaired kidney function. In a client receiving chemotherapy, an elevated BUN level may suggest chemotherapy-induced nephrotoxicity or other kidney-related complications. Prompt reporting is crucial to ensure appropriate intervention and management of the client's kidney function.
B. While the platelet count of 135,000/mm3 or 135 x 109/L is slightly below the normal reference range, it does not pose an immediate life-threatening risk. However, it should still be monitored and reported to the healthcare team for ongoing assessment and evaluation.
C. Decreased deep tendon reflexes may be an expected side effect of certain chemotherapy medications or a manifestation of neurotoxicity. While this finding should be documented and monitored, it is not as urgent as the elevated BUN level.
D. Periodic nausea and vomiting are common side effects of chemotherapy, but they may also be indicative of other underlying issues such as dehydration, electrolyte imbalances, or gastrointestinal complications. While this finding should be addressed and managed, it is not the highest priority compared to the elevated BUN level.
Correct Answer is D
Explanation
Hives (also known as urticaria) are raised, red, itchy welts on the skin that can be caused by an allergic reaction to medication, including antibiotics. It is essential for the PN to recognize this potentially severe allergic reaction and take immediate action.
Immediate action steps include:
- Stop the infusion of the intravenous antibiotic immediately.
- Notify the healthcare provider and report the allergic reaction.
- Assess the client's airway, breathing, and circulation to ensure there are no signs of respiratory distress or anaphylaxis.
- Administer prescribed emergency medications if needed (e.g., epinephrine, antihistamines).
- Monitor the client closely for any further signs of an allergic reaction or anaphylaxis.
The other assessment findings mentioned are also important to address, but they do not require immediate action:
A- Dry mouth with thirst: This may indicate dehydration, which should be addressed by encouraging the client to drink fluids, but it does not pose an immediate threat to the client's safety.
B- Warm skin with elastic turgor: This suggests that the client is adequately hydrated, and the skin's elasticity is normal, which is a positive finding.
C- Low-grade fever with diaphoresis: A low-grade fever indicates a mild elevation in temperature, and diaphoresis (sweating) may be the body's response to regulate temperature. The PN should monitor the client's temperature and assess for other signs of infection, but this finding does not require immediate action
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