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
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
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The nurse's feelings of sadness, poor sleep, and mild depression after the death of the terminally ill client indicate that the nurse is experiencing grief, which is a normal reaction to loss. However, if the nurse is finding it difficult to cope with the grief or if the grief is significantly impacting the nurse's daily life and well-being, seeking therapy is the best action.
Option B suggests seeking therapy for dysfunctional grief, which can provide the nurse with professional support and coping strategies to navigate through the grieving process. Therapeutic interventions can help the nurse process the emotions associated with the loss and provide a safe space to express and explore feelings of grief and loss.
Options A, C, and D may be helpful in certain situations, but they may not directly address the nurse's unresolved grief:
A. Taking a leave of absence to pursue healing can be considered if the nurse's grief is severely impacting their ability to function and provide safe patient care. However, it may not be necessary for everyone, and seeking therapy would be a more specific and targeted approach to address the grief.
C. Using stress reduction strategies can be beneficial for managing stress and promoting overall well-being, but it may not directly address the specific grief experienced by the nurse after the client's death.
D. Seeking an informal forum for discussing death can be helpful in processing feelings and emotions related to death and loss. However, it may not provide the level of support and guidance that therapy can offer in resolving grief.
Correct Answer is C
Explanation
The client's observed behavior of pacing the hall with clenched fists and swearing at others indicates that they are in the escalation phase of the aggression cycle. During this phase, the individual's anger and agitation increase, and their behavior becomes more intense and aggressive. If not addressed promptly and effectively, the situation can escalate further and potentially lead to a crisis or violent outburst.
By intervening immediately and calmly, the nurse aims to prevent the situation from escalating further and moving into the crisis phase, where the risk of harm to the client and others is highest. Effective de-escalation techniques, such as using a calm and non-threatening demeanor, active listening, and providing clear and respectful communication, can help the client regain control and reduce their agitation.
Option A - Recovery: The recovery phase comes after the aggressive incident, during which the individual may feel remorse or embarrassment about their behavior.
Option B - Crisis: The crisis phase is the point where the individual's anger and agitation reach a peak, and there is a high risk of violence or harmful actions.
Option D - Triggering: The triggering phase is the initial phase of the aggression cycle, where the individual's anger begins to build, and certain triggers may set off their aggressive behavior.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
