A nurse assessing a client’s lung sounds hears continuous low-pitched harsh rattling sounds over the client’s trachea that are most evident on expiration and are decreased after coughing.
Which term is the appropriate choice to accurately document this lung sound?

Emptying the urine drainage bags at least once per shift is a task that can be delegated to unlicensed assistive personnel (UAP) assigned to a cardiac surgery unit.

This task does not require assessment, teaching, or evaluation skills that are beyond the scope of practice of UAP.

Choice A is wrong because teaching a client how to use a pillow to support an incision when coughing requires education and evaluation skills that are only within the scope of practice of licensed nurses.

Choice B is wrong because checking the pedal pulses of bed-bound clients requires assessment skills that are only within the scope of practice of licensed nurses.

Pedal pulses are important indicators of peripheral circulation and vascular status.

Choice C is wrong because ambulating the first-day postoperative clients requires assessment and evaluation skills that are only within the scope of practice of licensed nurses.

First-day postoperative clients may have complications such as bleeding, infection, or hypotension that need to be monitored by a nurse.

This is because the nurse’s reply does not address the client’s fear of radiation therapy, but rather provides factual information that may not be relevant or helpful to the client.

The nurse is not using a therapeutic communication technique, such as reflecting, exploring, or validating the client’s feelings.

Instead, the nurse is shutting down the communication and missing an opportunity to learn more about the client’s concerns and needs.

Choice A is wrong because the nurse is not confronting a painful subject, but rather avoiding it.

The nurse is not acknowledging the client’s fear or inviting the client to talk more about it.

Choice C is wrong because the nurse is not recognizing that the client needs information, but rather assuming that the client does.

The nurse is not asking the client what he or she wants to know about radiation therapy, but rather telling the client what he or she should know.

Choice D is wrong because the nurse is not perceiving that the client is ready to hear more about the treatment, but rather imposing information on the client.

The nurse is not assessing the client’s readiness to learn, but rather giving unsolicited advice.