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

Answer and Explanation

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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Correct Answer is D

Explanation

A. Systemic infection can cause fever, but older adults often present with atypical signs, including a lack of fever, rather than the classic response.
B. The presence of a productive cough, abnormal breath sounds, and shortness of breath suggests a respiratory infection rather than a cardiac issue.
C. While older adults may be more susceptible to hypothermia, the client’s symptoms align with infection rather than hypothermia.
D. "The client's normothermic temperature does not rule out the presence of an infection" is correct because older adults may have a blunted febrile response to infection due to age-related changes in thermoregulation. An absence of fever does not exclude infection in elderly patients.

A. Lithotomy B. Dorsal recumbent C. Sim's position D. Prone

Correct Answer is B

Explanation

A. Lithotomy position is used for gynecologic, rectal, or urologic exams and would not be comfortable for a client with low back pain.
B. Dorsal recumbent position is correct because it allows the client to lie on their back with knees bent, reducing strain on the lower back while facilitating assessment of the chest, extremities, and peripheral pulses.
C. Sim’s position is used for rectal examinations or enemas and is not ideal for assessing the chest and extremities.
D. Prone position (lying face down) would exacerbate low back pain and make it difficult to examine the chest and extremities.

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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?

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Correct Answer is D

Explanation

A nurse is preparing to examine the chest, extremities, and peripheral pulses of a client who has low back pain. What is the best position to place this client in to assure they are comfortable for the exam?

Correct Answer is B

Explanation

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