A nurse is auscultating a client's lungs during the initial assessment of the patient in the emergency room. The nurse hears wheezes on expiration in the lower posterior lobes bilaterally. Which of the following actions should the nurse do first?
Have the client cough, then listen again
Teach patient pursed-lip breathing
Check O₂ saturation and apply O₂
Administer nebulizer treatment
The Correct Answer is A
A. Having the client cough, then listening again is correct. Sometimes wheezing can be due to mucus or secretions in the airways, and coughing can help clear them. If wheezing persists, further assessment and interventions may be needed.
B. Teaching pursed-lip breathing is beneficial for chronic obstructive pulmonary disease (COPD) patients but is not the first action in an acute assessment.
C. Checking O₂ saturation and applying O₂ is important but not the first step. Oxygen therapy is not indicated unless there is evidence of hypoxia.
D. Administering a nebulizer treatment should only be done if wheezing persists and is causing respiratory distress, but the nurse should first confirm that the wheezing is not due to mucus plugging, which may resolve with coughing.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. The right lung is larger than the left to accommodate the heart’s position, but it is not precisely one third larger.
B. The lower lobes of both lungs are primarily located toward the posterior chest wall, not the anterior. When auscultating breath sounds in the lower lobes, the nurse should focus on the posterior thorax.
C. The right lung has three lobes (upper, middle, and lower), while the left lung has two lobes (upper and lower). This anatomical difference is important for respiratory assessment and auscultation.
D. The lungs are not structurally symmetrical; the left lung is smaller due to the cardiac notch. While there are minor functional differences, the primary distinction is anatomical.
Correct Answer is A
Explanation
A. Inflating the blood pressure cuff 30 mmHg above the point where the radial pulse disappears is correct. This method, known as the palpatory method, prevents auscultatory gap errors and ensures an accurate blood pressure reading.
B. Assisting the patient to a standing position for five to ten minutes is incorrect unless assessing for orthostatic hypotension. For routine blood pressure measurements, the client should be seated and at rest for at least five minutes.
C. Palpating the radial artery and placing the stethoscope lightly over this area is incorrect because blood pressure is auscultated over the brachial artery, not the radial artery.
D. Measuring the blood pressure cuff to encircle 60% of the client’s arm is incorrect. The correct guideline is that the cuff bladder should encircle at least 80% of the arm circumference, not 60%.
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