A nurse is auscultating a client’s lung sounds and identifies crackles in the left lower lobe. Which intervention should the nurse take first?

Repeat auscultation after asking the client to take a deep breath and cough.

Instruct the client to limit fluid intake to less than 2,000 mL/day.

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

Prepare to administer antibiotics.

Answer and Explanation

The Correct Answer is A

Choice A Reason:

Repeating auscultation after asking the client to take a deep breath and cough is the first intervention the nurse should take. This action helps to clear any secretions or mucus that might be causing the crackles. If the crackles persist after the client coughs, it indicates that the sounds are likely due to fluid in the lungs, which requires further assessment and intervention. This step ensures that the nurse accurately identifies the cause of the crackles before proceeding with other interventions.

Choice B Reason:

Instructing the client to limit fluid intake to less than 2,000 mL/day might be appropriate in cases of fluid overload or heart failure, but it is not the first intervention. The nurse needs to confirm the cause of the crackles before making any recommendations about fluid intake. Limiting fluid intake without proper assessment could lead to dehydration and other complications.

Choice C Reason:

Placing the client on bed rest in semi-Fowler’s position can help improve lung expansion and oxygenation by reducing pressure on the diaphragm. However, this is not the first intervention. The nurse should first determine if the crackles are due to secretions that can be cleared by coughing. Semi-Fowler’s position is beneficial for patients with respiratory distress, but it does not address the immediate need to reassess lung sounds.

Choice D Reason:

Preparing to administer antibiotics is not the first intervention. Antibiotics are used to treat infections, and the nurse needs to confirm whether the crackles are due to an infection or another cause before administering medication. Immediate administration of antibiotics without proper assessment could lead to inappropriate treatment and antibiotic resistance.

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Correct Answer is C

Explanation

Choice A Reason:

A client who is 3 days postoperative and has a nursing assistant helping him out of bed is at some risk for falls due to recent surgery and potential weakness. However, the presence of a nursing assistant reduces this risk significantly. Postoperative clients are often monitored closely and assisted with mobility to prevent falls.

Choice B Reason:

An adolescent client who has a leg fracture and has been using crutches for the past 2 weeks is at risk for falls due to the use of crutches and limited mobility. However, adolescents generally have better balance and coordination compared to older adults, and they adapt quickly to using mobility aids.

Choice C Reason:

An older adult client who is confused and has urinary frequency is at the greatest risk for falls. Confusion can lead to disorientation and poor judgment, increasing the likelihood of falls. Urinary frequency can cause the client to rush to the bathroom, further increasing fall risk. Older adults also tend to have decreased strength and balance, compounding the risk.

Choice D Reason:

A client with diabetes mellitus who has a leg ulcer is at risk for falls due to potential neuropathy and impaired mobility. However, this risk is generally lower compared to a confused older adult with urinary frequency. The leg ulcer may cause some mobility issues, but it does not typically lead to the same level of disorientation and urgency as urinary frequency.

A. Loperamide should not be used if diarrhea is infectious. B. You can take loperamide until the diarrhea stops. C. Loperamide has no side effects. D. Loperamide should not stop this type of diarrhea.

Correct Answer is A

Explanation

Choice A Reason:

Loperamide should not be used if diarrhea is infectious is correct. Loperamide is an antidiarrheal medication that works by slowing down gut movement. However, if the diarrhea is caused by an infection, such as from spoiled food, it is important to allow the body to expel the infectious agents. Using loperamide in such cases can prolong the infection and potentially worsen the condition.

Choice B Reason:

You can take loperamide until the diarrhea stops is incorrect. While loperamide can be effective for non-infectious diarrhea, it is not recommended for infectious diarrhea. Stopping the diarrhea prematurely can trap the infectious agents in the intestines, leading to more severe symptoms.

Choice C Reason:

Loperamide has no side effects is incorrect. Loperamide can have side effects, including constipation, dizziness, and abdominal pain. It is important to use this medication under the guidance of a healthcare provider, especially in cases of infectious diarrhea.

Choice D Reason:

Loperamide should not stop this type of diarrhea is incorrect. While it is true that loperamide should not be used for infectious diarrhea, the statement is misleading. Loperamide can stop diarrhea, but it is not appropriate for all types of diarrhea, particularly those caused by infections.

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A nurse is auscultating a client’s lung sounds and identifies crackles in the left lower lobe. Which intervention should the nurse take first?

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Naxlex Comprehensive Predictor Exams

A nurse on the medical-surgical unit is conducting a fall risk assessment on four clients. Which of these clients would be at greatest risk for falls?

Correct Answer is C

Explanation

A nurse is caring for a client with numerous episodes of watery diarrhea. The client reports eating some spoiled deli meat earlier in the day. The client asks if they should take loperamide (Imodium) to stop the diarrhea. What would be an appropriate response from the nurse?

Correct Answer is A

Explanation

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