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 ["500"]
Explanation
1 liter is equal to 1000 milliliters. Therefore, to calculate the fluid intake in mL, we can multiply 1/2 liter by 1000 mL/liter:
1/2 liter * 1000 mL/liter = 500 mL
So, the practical nurse should document 500 mL as the client's fluid intake.
Correct Answer is A
Explanation
The client's statements suggest significant distress, feelings of being a burden, and a sense of hopelessness related to their obsessive-compulsive disorder (OCD). Given the severity of these statements, it is crucial for the PN to assess the client's risk of suicide or self-harm. Asking directly about suicidal thoughts or considering suicide as an option allows the PN to evaluate the immediate safety of the client and take appropriate actions to ensure their well-being.
While the other options may also provide relevant information, they are not as critical as assessing the client's risk of suicide.
B. Questioning about which rituals are most often used to reduce anxiety can help gather information about the client's specific OCD symptoms and coping mechanisms.
C. Determining what makes the client think people are laughing can provide insight into their perception of how others view them, but it may not address the immediate risk of harm.
D. Asking about the impact of obsessions and compulsions on sleep can help assess the client's overall functioning, but it does not address the immediate risk of suicide.
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