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 B

Explanation

Choice A rationale
Requesting a prescription for the insertion of an indwelling urinary catheter is not the best option to prevent skin breakdown in a client with urinary incontinence. Catheters can increase the risk of urinary tract infections and should be used as a last resort.
Choice B rationale

Applying a moisture barrier ointment to the skin can help protect the skin from the damaging effects of urine. This can help prevent skin breakdown and is a common practice in the care of clients with urinary incontinence.
Choice C rationale
Cleaning the skin and perineum with hot water after each episode of incontinence is not recommended. Hot water can dry out the skin and cause irritation. It’s better to use warm water and a gentle cleanser.
Choice D rationale
Checking the client’s skin every 8 hours for signs of breakdown is important, but it’s not the only action the nurse should take. The nurse should also take proactive measures to protect the skin, such as applying a moisture barrier ointment.

A. Provide an adaptive feeding device for the client. B. Place the client in a lateral position. C. Arrange the food groups clockwise on the plate. D. Initiate a liquid diet for the client.

Correct Answer is A

Explanation

The correct answer is choice A: Provide an adaptive feeding device for the client.

Choice A rationale: Providing an adaptive feeding device, such as a built-up utensil or a swivel spoon, can help clients with limited hand movement feed themselves independently. These devices are designed to make grasping and manipulating utensils easier, promoting independence and self-care.

Choice B rationale: Placing the client in a lateral position might not directly address the issue of limited hand movement, and it could even make feeding more challenging. This position is typically used for clients with swallowing difficulties or those at risk of aspiration.

Choice C rationale: Arranging food groups clockwise on the plate may help clients with visual impairments or cognitive issues, but it would not directly assist a client with limited hand movement during feeding.

Choice D rationale: Initiating a liquid diet for the client is not the most appropriate initial action to address limited hand movement. This might be considered as a last resort if the client is unable to feed themselves with any type of adaptive device or assistance. The priority should be promoting independence and providing appropriate tools to support self-feeding.

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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

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client with urinary incontinence. What action should the nurse take to prevent skin breakdown?

Correct Answer is B

Explanation

A nurse is caring for a client whose hand movement is limited. What action should the nurse take to assist the client with feeding?

Correct Answer is A

Explanation

A nurse is about to take a client’s oral temperature, but the client has just consumed some ice chips. What should the nurse do next?

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A nurse is caring for a client who requires a clear liquid diet. Which food is acceptable for the client to consume?

A client is receiving oxygen at 2 L/min via a nasal cannula. What oxygen concentration is the client receiving?

A nurse in a long-term care facility is taking care of a patient who is unresponsive. What action should the nurse take when performing oral hygiene for the patient?

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A home health nurse is conducting a home-safety risk appraisal for an older adult client. Which of the following findings should the nurse identify as a safety risk for the client? (Select all that apply.)

A nurse is at a social event when another guest suddenly coughs weakly once, grasps her throat with her hands, and is unable to speak. What action should the nurse take?