Upon auscultating a client’s lungs, the nurse identifies crackles in the left posterior base. What action should the nurse take?
Prepare to administer antibiotics.
Instruct the client to limit fluid intake to less than 2,000 m/day.
Initiate bedrest in semi-Fowler’s position.
Repeat the auscultation after asking the client to breathe deeply and cough.
The Correct Answer is D
Choice A rationale
While antibiotics are used to treat bacterial infections, crackles in the lungs can be a sign of various conditions, not just bacterial infections. Therefore, administering antibiotics is not the appropriate action based solely on the finding of crackles.
Choice B rationale
Limiting fluid intake can be beneficial for clients with certain conditions such as heart failure, but it is not the appropriate action based solely on the finding of crackles.
Choice C rationale
Initiating bedrest in semi-Fowler’s position can help improve lung expansion and ease breathing in clients with certain respiratory conditions. However, it is not the appropriate action based solely on the finding of crackles.
Choice D rationale
Crackles can sometimes be cleared by deep breathing and coughing. Repeating the auscultation after asking the client to breathe deeply and cough can help the nurse determine if the crackles are transient (cleared by coughing) or persistent.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Cranberry juice is an acceptable component of a clear liquid diet. Clear liquid diets are often prescribed postoperatively as they are easy to digest and leave no residue in the digestive tract.
Choice B rationale
Lemon sherbet is not part of a clear liquid diet. It is considered part of a full liquid diet, which is more substantial and includes foods that are liquid at room temperature.
Choice C rationale
Carrot juice is not typically included in a clear liquid diet. It may contain pulp and is not clear, which is a requirement of a clear liquid diet.
Choice D rationale
Plain yogurt is not part of a clear liquid diet. It is considered a solid food and is therefore not included.
Correct Answer is D
Explanation
Choice A rationale
While antibiotics are used to treat bacterial infections, crackles in the lungs can be a sign of various conditions, not just bacterial infections. Therefore, administering antibiotics is not the appropriate action based solely on the finding of crackles.
Choice B rationale
Limiting fluid intake can be beneficial for clients with certain conditions such as heart failure, but it is not the appropriate action based solely on the finding of crackles.
Choice C rationale
Initiating bedrest in semi-Fowler’s position can help improve lung expansion and ease breathing in clients with certain respiratory conditions. However, it is not the appropriate action based solely on the finding of crackles.
Choice D rationale
Crackles can sometimes be cleared by deep breathing and coughing. Repeating the auscultation after asking the client to breathe deeply and cough can help the nurse determine if the crackles are transient (cleared by coughing) or persistent.
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