A nurse auscultates a client's lung sounds and identifies crackles in the left lower lobe. Which of the following interventions should the nurse take

Place the client on bed rest in a semi-Fowler's position.

Instruct the client to limit fluid intake to less than 2.000 mL/day.

Prepare to administer antibiotics.

Repeat auscultation after asking the client to breathe deeply and cough

Answer and Explanation

The Correct Answer is D

A- Positioning in semi-Fowler’s can aid breathing but doesn’t assess crackles’ cause. It’s supportive, not diagnostic, and premature without further data

B-Instructing the client to limit fluid intake to less than 2,000 mL/day is not indicated for crackles. Fluid restriction is more commonly used in conditions like congestive heart failure where there is excessive fluid retention.

C- Preparing to administer antibiotics is not the first intervention for crackles. Crackles can be caused by various conditions, and antibiotics would only be administered if there is an underlying infection requiring treatment.

D- Reassessing after deep breathing and coughing evaluates secretion clearance, aligning with nursing assessment and Maslow’s physiological needs

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Correct Answer is ["2"]

Explanation

To calculate the amount of naloxone to administer, you can use the following formula:

Amount to administer (mL) = Total dose required (mg) / Concentration of drug (mg/mL)

Given:

Total dose required = 0.4 mg

Concentration of drug = 0.2 mg/mL

Let's calculate the amount to administer:

Amount to administer (mL) = 0.4 mg / 0.2 mg/mL

Now, perform the calculation:

Amount to administer (mL) = 2 mL

So, the nurse should administer 2 mL of naloxone intravenously as a bolus dose to the client.

A. Ask the client if they are in denial regarding the seriousness of their illness. B. Be an active listener and use silence to facilitate communication. C. Refer the client to the chaplain for religious counseling. D. Inform the client that since it is too late to change, acceptance is inevitable.

Correct Answer is B

Explanation

Using active listening techniques and providing a supportive and non-judgmental environment can promote the client's ability to express their feelings. Many clients facing end-stage illnesses, such as alcoholic cirrhosis, may experience a range of emotions and find it difficult to talk about their illness or impending loss of life. By being present, attentive, and using silence when appropriate, the nurse allows the client the space and time they need to process their thoughts and emotions and feel comfortable expressing their feelings when they are ready.

Incorrect:

Option A may come across as confrontational and judgmental, which can hinder the client's willingness to share their feelings.

Option C may be appropriate if the client requests spiritual or religious support, but it should not be assumed as the primary intervention for promoting emotional expression.

Option D can be seen as dismissive and insensitive to the client's emotional needs, and it may not be helpful in encouraging the client to open up about their feelings.

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A nurse auscultates a client's lung sounds and identifies crackles in the left lower lobe. Which of the following interventions should the nurse take

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Naxlex Comprehensive Predictor Exams

Correct Answer is ["2"]

Explanation

A client with end-stage alcoholic cirrhosis of the liver is hesitant to talk about the illness and the impending loss of life from their alcohol use disorder. Which action by the nurse can promote the client's ability to express their feelings?

Correct Answer is B

Explanation

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A nurse auscultates a client's lung sounds and identifies crackles in the left lower lobe. Which of the following interventions should the nurse take