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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale
Increasing the client’s oral fluid intake is not the immediate action the nurse should take. While hydration is important, it does not directly address the client’s low oxygen saturation.
Choice B rationale
Initiating humidification therapy can help to thin secretions and improve oxygenation, but it is not the immediate action the nurse should take.
Choice C rationale
Raising the head of the bed is the first action the nurse should take. This position can help to improve lung expansion and oxygenation.
Choice D rationale
Encouraging the client to cough and deep breath can help to clear secretions and improve oxygenation, but it is not the immediate action the nurse should take.

A. Skim milk B. Carrot juice C. Grape juice D. Chicken broth

Correct Answer is D

Explanation

Choice A rationale
Skim milk is not acceptable for a client on a clear liquid diet. Clear liquid diets only include liquids that you can see through, and milk is not a clear liquid.
Choice B rationale

Carrot juice is not acceptable for a client on a clear liquid diet. While it is a liquid, it is not clear, and therefore does not meet the criteria for a clear liquid diet.
Choice C rationale
Grape juice is acceptable for a client on a clear liquid diet, as long as it is without pulp. Clear fruit juices are typically included in a clear liquid diet.
Choice D rationale
Chicken broth is acceptable for a client on a clear liquid diet. Broths are clear liquids and are often included in a clear liquid diet to provide some savory flavor.

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Upon auscultating a client’s lungs, the nurse identifies crackles in the left posterior base. What action should the nurse take?

Nursing Test Bank

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