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 A

Explanation

Choice A Reason:

Washing the area of the puncture thoroughly with soap and water is the first and most immediate action the nurse should take. This step helps to reduce the risk of infection by removing any potential contaminants from the puncture site. It is a crucial initial response to any needlestick injury to minimize the risk of bloodborne pathogen transmission. Proper hand hygiene is essential in preventing infections and ensuring the safety of healthcare workers.

Choice B Reason:

Notifying employee health services is an important step that should follow the initial first aid. Employee health services will provide further evaluation, testing, and follow-up care as needed. They will also guide the nurse on any necessary post-exposure prophylaxis and additional steps to take. However, this is not the first action to take immediately after the injury.

Choice C Reason:

Completing an incident report is a necessary step to document the needlestick injury. This report helps in tracking and preventing future incidents, ensuring that proper protocols are followed, and providing data for workplace safety improvements. While important, this step should be taken after the initial first aid and notification of employee health services.

Choice D Reason:

Reporting the incident to the charge nurse is also an important step in the process. The charge nurse needs to be informed about the incident to ensure that appropriate follow-up actions are taken and to provide support to the affected nurse. However, this step should come after the immediate first aid and notification of employee health services.

A. Defamation of character B. Invasion of privacy C. Slander D. False imprisonment

Correct Answer is D

Explanation

Choice A Reason:

Defamation of character is incorrect. Defamation of character involves making false statements about someone that damage their reputation. This can be in the form of slander (spoken) or libel (written). Applying restraints without proper justification does not fall under defamation of character.

Choice B Reason:

Invasion of privacy is incorrect. Invasion of privacy involves intruding into someone’s personal life without consent. This can include unauthorized access to personal information or spaces. Applying restraints without proper justification is not an invasion of privacy.

Choice C Reason:

Slander is incorrect. Slander is a form of defamation that involves making false spoken statements that damage someone’s reputation. Applying restraints without proper justification does not involve making false statements.

Choice D Reason:

False imprisonment is correct. False imprisonment involves restraining a person without legal justification or their consent. In a healthcare setting, applying restraints without proper justification or following legal and ethical guidelines constitutes false imprisonment and violates the client’s rights.

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